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Nurses Partners in Asthma Care by Adela Sanders

VIEWS: 114 PAGES: 68

									NURSES:
PARTNERS IN
ASTHMA CARE




NIH P UBLICATION

N O . 95-3308

OCTOBER 1995



N ATIONAL I NSTITUTES

OF   H EALTH

National Heart, Lung,

and Blood Institute



                        i
T ABLE          OF      C ONTENTS




PREFACE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .    vi
NURSES’ ASTHMA EDUCATION WORKING GROUP . . . . . .                                         vii

1. PATHOPHYSIOLOGY OF ASTHMA . . . . . . . . . . . . . . . . .                              1

2. PRACTICAL GUIDE TO ASTHMA MANAGEMENT . . . . . .                                         3
     GOALS OF ASTHMA MANAGEMENT . . . . . . . . . . . . . . .                               3

     GENERAL PRINCIPLES OF ASTHMA MANAGEMENT . . .                                          3

     FOUR COMPONENTS OF ASTHMA MANAGEMENT . . . .                                           4
       Asthma Management Component 1:
       Objective Measures of Lung Function . . . . . . . . . . . .                          4

           Spirometry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .       4

           Peak Flow Monitoring . . . . . . . . . . . . . . . . . . . . . .                 6
           Actions/Implications for Nurses:
           Objective Measures . . . . . . . . . . . . . . . . . . . . . . . . .             6

       Asthma Management Component 2:
       Environmental Control Measures. . . . . . . . . . . . . . . .                        6

           Allergens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .      7
           Irritants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .    7

           Actions/Implications for Nurses:
           Environmental Control . . . . . . . . . . . . . . . . . . . . . .                7

        Asthma Management Component 3:
        Pharmacologic Therapy . . . . . . . . . . . . . . . . . . . . . . .                 8
           Two Major Groups of Asthma Medications:
           Anti-inflammatory and Bronchodilator . . . . . . . .                             8

           Step-Care for Chronic Asthma and Acute
           Asthma Episodes . . . . . . . . . . . . . . . . . . . . . . . . . . .            8

           Written Medication Plans for Patients—
           An Important Aid . . . . . . . . . . . . . . . . . . . . . . . . . .             9
           Recommendations for Exercise-Induced
           Asthma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .       9




ii
                                                                                              Table of Contents




          Actions/Implications for Nurses:
          Pharmacologic Therapy . . . . . . . . . . . . . . . . . . . . .                11
       Asthma Management Component 4:
       Patient Education . . . . . . . . . . . . . . . . . . . . . . . . . . . .         12

          Planning Patient Education:
          Keys to Success . . . . . . . . . . . . . . . . . . . . . . . . . . . .        12

          Implementing Patient Education:
          Effective Strategies . . . . . . . . . . . . . . . . . . . . . . . . .         13
              Help Patients Plan and Take Action . . . . . . . . .                       13

              Build Confidence: Teach Patients
              To Do the Asthma Management
              Activities Correctly . . . . . . . . . . . . . . . . . . . . . . .         14

              Help Patients Remember Your Verbal
              and Written Communications . . . . . . . . . . . . . .                     16
              Help Patients Understand and Remember
              Written Information . . . . . . . . . . . . . . . . . . . . . .            16

          Actions/Implications for Nurses:
          Patient Education . . . . . . . . . . . . . . . . . . . . . . . . . .          16

3. WORKING WITH PATIENTS FROM DIFFERENT
   CULTURAL BACKGROUNDS . . . . . . . . . . . . . . . . . . . . . . .                    18
   APPRECIATING INDIVIDUAL PATIENTS FROM
   DIVERSE GROUPS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .          18

   TIPS FOR WORKING WITH PEOPLE FROM
   DIFFERENT CULTURAL BACKGROUNDS . . . . . . . . . . . . .                              18

4. WORKING WITH CHILDREN AND
   ADOLESCENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .         22
   INFANTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   22

   TODDLERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .      24

   PRESCHOOL CHILDREN . . . . . . . . . . . . . . . . . . . . . . . . . .                25
   SCHOOL-AGE CHILDREN . . . . . . . . . . . . . . . . . . . . . . . . .                 26

   ADOLESCENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .         27

5. WORKING WITH ADULTS AT DIFFERENT AGES . . . . . . .                                   29
   TIPS FOR WORKING WITH ADULTS . . . . . . . . . . . . . . . . .                        29

   SPECIAL CONSIDERATIONS FOR YOUNG ADULTS . . . . .                                     29

   SPECIAL CONSIDERATIONS FOR OLDER ADULTS . . . . . .                                   30




                                                                                                             iii
Table of Contents




6. SPECIAL CONSIDERATIONS FOR SURGERY
   AND GASTROESOPHAGEAL REFLUX PATIENTS . . . . . . .                                    31
     SURGERY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   31

     GASTROESOPHAGEAL REFLUX . . . . . . . . . . . . . . . . . . . .                     31

7. RESOURCES TO MEET PATIENTS’ NEEDS . . . . . . . . . . . .                             32
     FINANCIAL ASSISTANCE . . . . . . . . . . . . . . . . . . . . . . . . .              32

        Health Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . .       32

        Government-Sponsored Programs . . . . . . . . . . . . . . .                      32
        Voluntary Organizations Assistance . . . . . . . . . . . . .                     32

        Health Care and Equipment Providers . . . . . . . . . . . .                      33

        Actions/Implications for Nurses . . . . . . . . . . . . . . . . .                33
8. SOURCES OF ASTHMA INFORMATION
   AND MATERIALS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .           34

     SOURCES OF PATIENT EDUCATION MATERIALS
     AND AIDS FOR NURSES . . . . . . . . . . . . . . . . . . . . . . . . . .             34

     SELECTED RESOURCE PUBLICATIONS . . . . . . . . . . . . . . .                        34
     NAEPP MATERIALS . . . . . . . . . . . . . . . . . . . . . . . . . . . . .           35

Appendix A: DOSAGES AND SIDE EFFECTS
            OF MEDICATIONS FOR CHRONIC
            ASTHMA . . . . . . . . . . . . . . . . . . . . . . . . . . . .               36

Appendix B: DOSAGES FOR ACUTE
            EXACERBATIONS OF ASTHMA . . . . . . . . . . .                                42
Appendix C: ASSESSING AND MEETING NEEDS:
            EXAMPLES OF PATIENT EDUCATION
            FOR EACH CLINIC VISIT . . . . . . . . . . . . . . . . .                      44

Appendix D: PATIENT HANDOUTS . . . . . . . . . . . . . . . . . . .                       48

     How To Use Your Peak Flow Meter
     My Asthma Symptoms and Peak Flow Diary

     Asthma Management Plan

     How To Stay Away From Things That Make
     Your Asthma Worse
     Your Metered-Dose Inhaler: How To Use It

     Spacers: Making Inhaled Medicines Easier To Take

     How To Use and Care for Your Nebulizer




iv
FIGURES
Figure 1 Relationships between airway inflammation,
         airway hyperresponsiveness, airway
         obstruction, and asthma symptoms . . . . . . . . . .                             2

Figure 2 Medications used for each level of
         asthma severity . . . . . . . . . . . . . . . . . . . . . . . . . .             10

TABLES
Table 1       Correct technique for performing
              spirometry tests . . . . . . . . . . . . . . . . . . . . . . . . . .        5

Table 2       Classification of asthma by severity of
              disease before treatment . . . . . . . . . . . . . . . . . .                9

Table 3       Actions patients need to take:
              The goals of asthma patient education . . . . . . .                        13
Table 4       Illustration of the four R’s:
              Inhaler training . . . . . . . . . . . . . . . . . . . . . . . . . .       15

Table 5       A checklist for working with patients
              from different backgrounds/cultures . . . . . . . . .                      19

Table 6       Indicators of problems with asthma
              in infants and children . . . . . . . . . . . . . . . . . . . .            23
BOXES

Asthma is a chronic lung disease characterized by: . . . . . .                            1
Indicators for increasing preventive asthma
medications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .     9

Encourage patients with exercise-induced
asthma to: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   11

Questions for planning patient education . . . . . . . . . . . . .                       12
Two examples of traditional healing practices . . . . . . . . .                          20

Selected tips for preparing patients to care for
an asthma episode in infants, toddlers, and
preschoolers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   22




                                                                                              v
P REFACE




Asthma can be controlled when managed properly.       If you want more detailed or technical
This guide will help nurses in physician’s offices,   information on asthma management, refer to
clinics, hospitals, schools, and worksites to         the Executive Summary of the National Asthma
establish and maintain a partnership with patients    Education and Prevention Program’s Guidelines
to help them manage their asthma. Moreover,           for the Diagnosis and Management of Asthma on
the guide will help nurses assess patient needs,      which this guide is based. (See Selected
tailor management plans, educate patients to          Resource Publications, page 34.)
follow their management plan, and coordinate
the overall plan of care with other health            Please take the time to become familiar with
professionals. Tips are provided for working          this guide; then refer to it as needed. Please
with patients of all ages and cultural backgrounds    send any suggestions for improving the guide or
and in different health care settings.                descriptions of how you used it in your work to:

The nurses who developed this guide know                National Asthma Education
firsthand that nurses want very practical                 and Prevention Program
information on asthma management. A needs               NHLBI Information Center
assessment of nurses in clinical and hospital           P.O. Box 30105
settings found overwhelmingly that nurses               Bethesda, MD 20824-0105
wanted information they could use and convey
to patients easily. Thus, the decision was made
to limit theoretical explanations, technical terms,
and complex discussions of pathophysiology in         Claude Lenfant, M.D.
this guide.
                                                      Director, National Heart, Lung, and Blood Institute
                                                      Chairman, National Asthma Education and
                                                        Prevention Program Coordinating Committee




vi
NURSES ’ A STHMA E DUCATION W ORKING G ROUP
Joan E. Blair, R.N., M.P.H.*                     Dorothy Page, R.N.C., M.S.N.*
Silver Spring, Maryland                          Coordinator
                                                 Pediatric Pulmonary and Home Care Program
Susan B. Clark, R.N., M.N.                       University of Massachusetts Medical Center
Coordinator, Pulmonary Rehabilitation            Worcester, Massachusetts
Division of Pulmonary Medicine
Cedars Sinai Medical Center                      Barbara Santamaria, R.N., M.P.H.
Los Angeles, California                          Hospital-Based Home Care Program
                                                 Veterans’ Administration Medical Center
Brenda H. Conner, L.P *.N.                       Baltimore, Maryland
Director, Center for Asthma and Allergy
 Education                                       National Heart, Lung, and Blood Institute Staff
Atlanta Allergy Clinic                           Matilde Alvarado, R.N., M.S.N.*
Atlanta, Georgia                                 Office of Prevention, Education, and Control
                          .,
Sheila Fitzgerald, C.R.N.P Ph.D.                 Ted Buxton, M.P.H.*
Assistant Professor                              National Asthma Education and Prevention
Division of Occupational Health                   Program
School of Hygiene and Public Health
Johns Hopkins University                         Virginia S. Taggart, M.P.H.
Baltimore, Maryland                              Division of Lung Diseases
Vivian Haines, R.N., M.S., S.N.P.                Robinson Fulwood, M.S.P.H.
Rushland, Pennsylvania                           Coordinator
                                                 National Asthma Education and Prevention
Marilyn Hartsell, R.N., M.S.N.                    Program
Case Manager
Blue Cross/Blue Shield of the National Capital   R.O.W. Sciences, Inc., Staff
 Area
Washington, D.C.                                 Lisa Caira, Program Specialist

Karen Huss, R.N., D.N.Sc., CANP*                 Doug Bishop, Graphic Artist
Assistant Professor                              Keith Stanger, Graphic Artist
School of Nursing
Johns Hopkins University                         Lucy Blanton, Editor
Baltimore, Maryland                              Donna Selig, Editor
Berri Mitchell, R.N., M.S.N.*                    Catherine Hageman, Word Processor
Patient Education Coordinator
Kansas City Allergy and Asthma Associates, PA    Ruth Thompson, Word Processor
Principal, Asthma Educators, Inc.                Sonia Van Putten, Word Processor
Overland Park, Kansas




*Principal writers


                                                                                                vii
PATHOPHYSIOLOGY                   OF    A STHMA                                                                   1


   ASTHMA IS      A   C HRONIC LUNG D ISEASE C HARACTERIZED          BY :


   s   Airway inflammation.
   s   Airway hyperresponsiveness to a variety of stimuli.
   s   Airway obstruction (or airway narrowing) that is partially or completely reversible either
       spontaneously or with treatment.




The underlying problem in asthma is airway                which is characterized by an excessive narrowing of
inflammation. Asthma results from complex                 the airways in response to a variety of stimuli.
interactions among a variety of inflammatory cells,
mediators, and the cells and tissues in the airways.      Airway obstruction or narrowing causes the
See figure 1.                                             symptoms of coughing, wheezing, chest tightness,
                                                          shortness of breath, and decreased endurance.
First, stimuli activate the release of inflammatory       Airway obstruction can develop gradually or
mediators from mast cells, macrophages, eosino-           abruptly.
phils, and other inflammatory cells within the
airways. These stimuli may include indoor and             For about half the asthma patients who inhale an
outdoor allergens, irritants, viral respiratory infec-    allergen, symptoms recur 4 to 8 hours after the
tions, cold air, and exercise.                            initial narrowing of the airways. This late-phase
                                                          response may be more severe and prolonged than
Next, the inflammatory mediators signal other             the earlier response.
inflammatory cells to migrate into the airways
and to become activated. The activation of these          Reducing airway inflammation can lessen airway
inflammatory cells and the release of more inflam-        hyperresponsiveness, lessen asthma symptoms,
matory mediators lead to epithelial injury, increased     and decrease the need for frequent use of
smooth muscle contraction and mucus secretion,            bronchodilators—in other words, control asthma.
swelling, and changes in the parasympathetic              Airway inflammation can be reduced greatly
control of airway function.                               by decreasing or eliminating exposure to the
                                                          allergens, irritants, or other stimuli that provoke
This results in the airways becoming more                 an asthma episode and by taking anti-inflammatory
narrow and obstructed. These inflammatory                 medication daily.
processes also lead to airway hyperresponsiveness,




                                                                                                              1
Pathophysiology of Asthma




Figure 1


    R ELATIONSHIPS B ETWEEN A IRWAY INFLAMMATION, AIRWAY HYPERRESPONSIVENESS ,
    A IRWAY OBSTRUCTION , AND ASTHMA SYMPTOMS

                                                Stimuli
                                     s   Allergen s Cold air
                                     s   Irritant   s Exercise

                                     s   Virus




                                          Activation of
                                       Inflammatory Cells
                             s   Mast cells      s Eosinophils

                             s   Macrophages s T-Lymphocytes


                                    Inflammatory Mediators



                                 Migration Into Airways and
                            Activation of More Inflammatory Cells
                               s Neutrophils    s Lymphocytes

                               s Eosinophils    s Monocytes




                                    Inflammatory Mediators




                                                                            Airway Obstruction
           Airway
     Hyperresponsiveness                                            s   Contraction of airway
                                                                        smooth muscle
                                                                    s   Swelling
                                                Stimuli
                                                                    s   Mucus secretion
                                     s   Allergen s Cold air
                                     s   Irritant   s Exercise

                                     s   Virus
                                                                            Asthma Symptoms
                                                                        s   Wheezing
                                                                        s   Shortness of breath
                                                                        s   Coughing
                                                                        s   Chest tightness




2
PRACTICAL G UIDE                 TO    ASTHMA MANAGEMENT


                                                                                                                  2

This section provides a practical summary of
asthma management for nurses in any setting and
addresses the following:
s   Goals of asthma management.
s   General principles of asthma management.
s   Four components of asthma management.
Subsequent sections discuss special considerations
for managing asthma in selected settings and with
patients of various ages and cultural backgrounds.
                                                         Goal: full participation in physical activities.

GOALS OF ASTHMA MANAGEMENT
The goals of asthma management are to:                   GENERAL PRINCIPLES OF ASTHMA
                                                         MANAGEMENT
s   Maintain normal activity levels (including
                                                         The principles of asthma management listed below
    exercise).
                                                         will help guide your approach to asthma manage-
s   Maintain (near) normal pulmonary function            ment.
    rates.
                                                         s   Long-term, ongoing care is required to
s   Prevent chronic and troublesome symptoms                 control symptoms, prevent acute asthma
    (e.g., coughing or breathlessness at night, in the       episodes, and reduce persistent airway inflam-
    early morning, or after exertion).                       mation caused by this chronic disease.
s   Prevent recurrent episodes of asthma                 s   Prevention of acute episodes is a key ingre-
    (e.g., no hospitalizations or emergency depart-          dient for achieving asthma control. This can be
    ment visits).                                            achieved by avoiding allergens or irritants and
                                                             pretreating before exercise or exposure to other
s   Avoid adverse effects from asthma medica-
                                                             stimuli. In addition, patients with moderate or
    tions.
                                                             severe asthma can prevent episodes by taking
Most asthma patients will be able to achieve the             anti-inflammatory medication daily.
goals of asthma management with proper therapy.
                                                         s   Anticipatory or early treatment of symptoms
These goals can be used as the basis for initial and
                                                             is important to reduce the likelihood of devel-
followup assessments, as will be discussed later.
                                                             oping severe airway narrowing. Early warning




                                                                                                              3
Practical Guide to Asthma Management




    signs that should be treated immediately include
    (1) a peak flow rate 20 percent below predicted
    or personal best (peak flow rates will be described
    in more detail later), (2) cough, (3) wheeze, (4)
    tightness of the chest, (5) shortness of breath, or
    (6) other individual signals a patient may have of
    an upcoming episode.
s   Objective measurement of asthma severity
    should guide the management of asthma.
s   Management activities should focus on (1)
    reducing airway inflammation to prevent
    asthma episodes and (2) relieving airway
    narrowing when necessary. This principle is           Coach
    based on the current understanding of the             patients to
                                                          use correct
    pathophysiology of asthma.
                                                          technique.

FOUR COMPONENTS OF ASTHMA MANAGEMENT
                                                          lung function are obtained with spirometers and
Your encounters with asthma patients can be
                                                          peak flow meters.
organized around the four components of asthma
management, which are listed below and then               Spirometry
explained in more detail.                                 The spirometric measurements most often used are:
1. Objective measures of lung function to both            s   Forced expiratory volume in 1 second
   assess and monitor each patient’s asthma.                  (FEV1)—the amount of air forcefully blown out
2. Environmental control efforts to reduce or                 in the first second. FEV1 is one of the most
   eliminate exposure to allergens and irritants              useful measures because it indicates both large
   (often called asthma triggers) that induce airway          and small airway function.
   inflammation and precipitate acute asthma              s   Peak expiratory flow rate (PEFR)—the highest
   episodes.                                                  flow rate that can be created by the patient
3. Pharmacologic therapy to prevent, reverse, and             forcefully blowing with fully inflated lungs.
   control airway inflammation and obstruction.               PEFR correlates well with FEV1 although it
                                                              primarily measures large airway function. PEFR
4. Patient education to help patients prepare and             measurements are made in liters per minute.
   follow their daily management plan and their
   action plan for dealing with symptoms.                 s   Forced vital capacity (FVC)—the total volume
                                                              of air that the patient can blow out as rapidly as
Asthma Management Component 1:                                possible. FVC is a good indicator of patient effort
Objective Measures of Lung Function                           and also may help determine airway obstruction.
Objective measures of lung function are important         s   Maximum midexpiratory flow rate (MMEF)—
for making a diagnosis, assessing the severity of
                                                              the flow measured between 25 and 75 percent
asthma, and developing and using asthma control
                                                              of the forced expiratory volume. MMEF mea-
plans. They provide an accurate way of assessing
                                                              surements assess small airway function.
lung function. Attempts to assess lung function
through physical examinations and patients’ reports       Nurses can instruct and work with patients to
are often inaccurate. Objective measurements of           ensure that lung function evaluations are made


4
                                             Asthma Management Component 1: Objective Measures of Lung Function




with correct, reproducible techniques. (See table 1.)            Selected Resource Publications section.) Pulmon-
Information about spirometry and spirometers is                  ologists, allergists, and respiratory therapists are
available in the manufacturers’ manuals and from                 also valuable sources of information.
the American Lung Association. (See page 34 in

Table 1


    CORRECT TECHNIQUE              FOR   PERFORMING SPIROMETRY TESTS
    s     Keep conditions constant for each effort and each patient. Nose clips are recommended but optional,
          and the patient can sit or stand. Very obese patients should lean back slightly in their chairs.
    s     Record the descriptive data in the patient record (such as date, time, age, sex, height, and race) so you
          can find the corresponding predicted values for the patient. (Predicted values are average rates for
          persons the same sex, age, and height as the patient.) Check the height of growing children at each
          visit. If results seem dramatically different from what is expected, evaluate the patient’s effort and
          check the accuracy of the patient’s data.
    s     Explain and demonstrate the steps listed below. Then have the patient do these steps:

          1. Exhale comfortably.

          2. Inhale as deeply as possible.

          3. Place the spirometer mouthpiece between the teeth and seal the lips around it.
          4. Blow, pushing the air out quickly and forcefully.
          5. Continue to blow for at least 6 seconds “squeezing” all the air out.

          When the patient is blowing, the nurse or technician needs to encourage the patient strongly with
          calls to “Blow hard; push! push! push! keep going; breathe out more . . . Good effort.”
    s     Obtain at least three acceptable measurements. (See below for indicators of unsatisfactory spiromet-
          ric measurements.) Take no more than eight tries to achieve these three measurements during a
          single test session.


    INDICATORS        OF   UNSATISFACTORY SPIROMETRIC MEASUREMENTS
    According to the American Thoracic Society, any effort is considered unsatisfactory if any of the follow-
    ing occurs:
    s     Very hesitant or broken expiration at the beginning of the test (or an extrapolated volume of more
          than 5 percent of FVC or 0.100 L, whichever is greater).
    s     Coughing occurs during the first second of the test or interferes with measurement after the first
          second. (Coughing at the end of the FVC maneuver does not affect the FEV1 measurement.)
    s     The expiration stops after less than 6 seconds; expiration time longer than 6 seconds is needed for
          patients with obstructed airways.
    s     The mouthpiece is blocked. For example, the tongue or false teeth of the patient slip in front of the
          mouthpiece.
    s     Glottis closure (Valsalva maneuver) occurs. Indicators of glottis interference or closure include vocal
          sounds, rumbling in the throat, and flow volume curves with vertical jagged lines.
    s     A leak occurs. Patient’s lips lose their seal around the mouthpiece.




                                                                                                                        5
Practical Guide to Asthma Management




Peak Flow Monitoring
Portable peak flow meters measure PEFR. This
provides patients with an objective measure of their
lung function and helps them become actively
involved in managing their asthma. The PEFR
is the highest air flow rate that can be created by
patients forcefully blowing after fully inflating
their lungs. With a peak flow meter and proper
training, patients can detect when their asthma
is getting worse, often before symptoms occur.
Patients can also objectively assess the severity
                                                        Patients need to use the same peak flow meter once
of an asthma episode, which will indicate what          selected.
actions they should take. Peak flow measurements
can also assess the response to therapy. See the
patient handouts “How To Use Your Peak Flow             effective in decreasing the need for asthma medica-
Meter” and “Asthma Management Plan” (appendix           tions and in reducing symptoms. Environmental
D) for more information.                                stimuli that can make asthma worse include
                                                        airborne allergens and irritants, infections, and cold
                                                        air; nonenvironmental stimuli include exercise and
Actions/Implications for Nurses:                        strong emotional expressions that increase respira-
Objective Measures                                      tion, such as laughing, crying, yelling, and fear.
s   Ensure that patients obtain accurate spiro-
    metric readings by coaching them to use the         You can identify what makes a patient’s asthma
    correct technique.                                  worse by taking a thorough history of past asthma
                                                        episodes. If needed, have patients keep written
s   Use the handouts “How To Use Your Peak              records of all their episodes. The information you
    Flow Meter” and “Asthma Management                  want from patients includes:
    Plan” (see appendix D) to instruct patients
    how to use a peak flow meter, obtain their          s   The number of asthma episodes and how long
    personal best, and use peak flow readings to            they lasted.
    help them manage their asthma. Help patients        s   When symptoms first appeared.
    to be aware of other signs that indicate the need
    to take medications, such as coughing, wheez-
    ing, and difficulty breathing.
s   Ask all patients to demonstrate their PEFR
    technique at each visit. Use the five steps
    listed in “How To Use Your Peak Flow Meter”
    to check off each step they complete accurately.
                                                               HAIR
                                                              SPRAY
Asthma Management Component 2:
Environmental Control Measures
A variety of stimuli can increase airway inflam-
mation and bring on acute asthma episodes.
Eliminating or reducing exposure to these
stimuli—also called triggers—has proven to be           Avoiding triggers is potent anti-inflammatory therapy.




6
                                            Asthma Management Component 2: Environmental Control Measures




s   What patients suspected made their asthma
    worse.
s   Whether emergency department visits or
    hospitalizations were necessary.
s   What patients felt reduced the number of
    episodes.
Improvement in symptoms is often directly related
to the degree patients follow environmental control
recommendations. How well patients follow the             Ask smokers to quit smoking, then follow up with them.
recommendations is greatly affected by the strength
of the partnership established with the patient and
the completeness and quality of the patient educa-        perfume, hair spray, cooking odors, paint fumes,
tion provided. Develop with patients plans and            and insecticides), and occupational exposures to
methods they will use to stay away from asthma            airborne irritants. Outdoor irritants include air
triggers. Use the handout “How To Stay Away               pollutants, particularly ozone, nitrogen dioxide,
From Things That Make Your Asthma Worse” (in              and sulfur dioxide.
appendix D).
Allergens                                                 Actions/Implications for Nurses:
The majority of people with asthma have an allergic       Environmental Control
or IgE-mediated component to their asthma. For            s   Help patients eliminate—or reduce as much
many, exposure to allergens is the primary cause of           as possible—exposure to the things that
airway inflammation, hyperresponsiveness, and                 make their asthma worse. Use the handout
narrowing.                                                    “How To Stay Away From Things That Make
                                                              Your Asthma Worse” in appendix D. Highlight
The diagnosis of allergy is made after taking a
                                                              the control measures most appropriate for each
thorough history and then using skin tests or in
                                                              patient. Urge patients and their families to
vitro methods to assess sensitivity to the allergen(s).
                                                              attempt one or two control measures at a time,
The outdoor molds and pollens that commonly
                                                              starting with the least expensive and/or the
bring on allergic symptoms are usually seasonal.
                                                              most effective.
Exposure is year round for the most common
indoor allergens: house-dust mites, cockroach             s   Ask about the presence of smokers in every
feces, and animal dander.                                     household and advise them to quit. Recom-
                                                              mend to the smokers directly that they stop
There are three main treatments for allergies.                smoking for the health of the patient and for
These are listed in the order in which they should            themselves. Ask them to set a quit date, and
be tried: (1) reducing the exposure to the offending          refer them to quit-smoking materials and
allergens, (2) medications, and (3) immunotherapy.            programs. Follow up with all smokers periodi-
Irritants                                                     cally to assess and reinforce their progress in
Exposures to irritants should be minimized, espe-             thinking about or actually quitting. If the
cially for those irritants that patients know bring           smokers are not ready to quit, ask them not to
about acute asthma episodes. Indoor irritants                 smoke in the house or car and ask them to keep
include tobacco smoke, smoke from wood-burning                thinking about quitting. It is best for them to
stoves, strong odors and sprays (for example,                 quit.




                                                                                                              7
Practical Guide to Asthma Management




Asthma Management Component 3:                          Clearly distinguish and review at each visit
Pharmacologic Therapy                                   the medications patients are to take to relieve
To achieve the goals of asthma management listed        symptoms and those they are to take to prevent
on page 3, an individualized step-care approach to      symptoms. Ask patients to bring their medicines
medications needs to be used to (1) achieve long-       to their visits and label them with terms they
term control of asthma and (2) treat acute episodes     readily understand. Try the terms below to help
of asthma. The “steps” will be discussed after the      make the distinction with your patients:
asthma medications are described.
                                                        s   Inhaled anti-inflammatory medications
Two Major Groups of Asthma Medications:                     have been called “controllers,” “preventive,”
Anti-inflammatory and Bronchodilator                        “preventers (of symptoms),” and the medicine
Anti-inflammatory and bronchodilator medications            for the “quiet” part of asthma.
are used in step-care therapy to treat airway inflam-   s   Short-acting beta2-agonists have been called
mation and airway obstruction. (See appendices A            “symptom relievers,” “quick-relief medicine,”
and B for more details on these medications.)               “rescue medicine,” and the medicine for the
s   Anti-inflammatory medications prevent and               “noisy” part of asthma.
    reduce airway inflammation. Inhaled corticoste-     Step-Care for Chronic Asthma and Acute
    roids, cromolyn sodium, and nedocromil sodium       Asthma Episodes
    are taken daily to prevent symptoms and             Step-care for chronic asthma. Medications to
    keep asthma under control. Short courses of         prevent or control chronic symptoms are given to
    oral corticosteroids are used to help reverse the   patients in accordance with the severity of their
    increased inflammation of a severe acute episode,   asthma. The level of severity—mild, moderate,
    speed recovery, and prevent recurrence. Some-       severe—is based on chronic symptoms and PEFR.
    times, oral corticosteroids are used longer term    (See table 2.) The medication “steps” that corre-
    to control severe chronic asthma.                   spond to each level of severity are provided in
s   Bronchodilator medications relax bronchial          figure 2.
    smooth muscles. Short-acting inhaled beta2-         The medications and their dosages should be
    agonists are taken as needed to relieve symp-       adjusted until the goals of asthma management
    toms. Longer acting bronchodilators can help        are achieved. If control is sustained for 3 months,
    prevent symptoms, especially nighttime symp-        medications can be reduced with careful monitor-
    toms. Longer acting bronchodilators include         ing. Preventive medications should be added or
    extended-release theophylline or oral beta2-        increased if any one of the indicators listed in the
    agonists and long-acting inhaled beta2-agonists.    box is present. The most effective preventive
                                                        medications are inhaled anti-inflammatory
                                                        medications (inhaled corticosteroids,
                                                        nedocromil, cromolyn).
                                                        Step-care for acute episodes. Medications to
                                                        relieve acute episodes of asthma also are added in a
                                                        step-care pattern as needed. The handout “Asthma
                                                        Management Plan” (see appendix D) describes a
                                                        step-care pattern used to manage asthma. The
                                                        steps or “zones” are based on the severity of the
                                                        acute episode as measured by peak flow meters
Label the inhalers so patients know when to use them.
                                                        and symptoms.



8
                                                          Asthma Management Component 3: Pharmacologic Therapy




    INDICATORS        FOR   I NCREASING PREVENTIVE ASTHMA MEDICATIONS
    s     Acute asthma episodes occur more than twice a week.

    s     More than three to four doses of an inhaled short-acting beta2-agonist are used in a day.

    s     Inhaled short-acting beta2-agonists are taken daily.

    s     PEFR changes more than 20 percent from morning to afternoon or evening, or before and
          after taking short-acting beta2-agonists.



Written Medication Plans for Patients—                               s    Yellow zone—take medications to relieve
An Important Aid                                                          asthma episodes at home.
The Asthma Management Plan (see handout in
                                                                     s    Red zone—call doctor or seek emergency care.
appendix D) helps physicians and nurses to prepare
with patients a written individualized medication/                   See the handout for more details.
action plan for controlling chronic asthma symp-
toms and relieving acute asthma episodes. The                        Recommendations for Exercise-Induced Asthma
actions and medications patients should take                         All asthma patients should be encouraged to
within each zone are as follows:                                     exercise and to prevent exercise-induced asthma
                                                                     (EIA). EIA affects 70 to 90 percent of all patients
s   Green zone—stay away from things that make                       with asthma as well as 40 percent of children with
    their asthma worse. Take daily medications to                    allergies but no clinical signs of asthma. EIA is a
    control chronic symptoms.                                        narrowing of the airways that occurs after 6 to 8

Table 2


    CLASSIFICATION          OF   ASTHMA      BY   SEVERITY      OF       D ISEASE B EFORE TREATMENT *
    Characteristics                   Mild                   Moderate                         Severe
    Frequency of                      ≤2 times/week;         >2 times/week; may last          frequent exacerbations,
    exacerbations                     brief (<1 hour)        days; not frequently severe      often severe
    Frequency of symptoms             minimal                often                            continuous
    Exercise tolerance                good                   diminished                       poor; activity limited
    Frequency of nocturnal            ≤2 times/month         >2 times/week                    almost nightly, chest tight
    asthma                                                                                    in a.m.
    School or work attendance         good                   fair                             poor
    Pulmonary function
     Peak expiratory flow             >80%                   60–80%                           <60%
     rate (PEFR)
        PEFR variability              <20%                   20–30%                           >30%

        Spirometry                    minimal airway         airway obstruction               substantial airway ob-
                                      obstruction            evident with reduced             struction with increased
                                                             expiratory flow at low           lung volumes and marked
                                                             lung volumes                     unevenness of ventilation

    *After treatment, severity is determined by the minimum medications needed to maintain good health.




                                                                                                                            9
Practical Guide to Asthma Management




Figure 2


     MEDICATIONS USED          FOR   EACH LEVEL       OF   ASTHMA SEVERITY
     Severity                                                    Treatment

     Mild                Inhaled beta2-agonists as needed
                               – Before exercise or other stimuli
                               – For symptom relief

                         If daily use or >3 doses of beta 2-agonist per day*



     Moderate            Inhaled beta2-agonists as needed.
                         Inhaled anti-inflammatory agent—taken daily
                               – Inhaled corticosteroids
                               – Cromolyn
                               – Nedocromil

                                        If symptoms persist*



                         Inhaled beta2-agonists as needed.
                         Inhaled corticosteroids (higher dose)
                               – With or without cromolyn or nedocromil
                               – With or without extended-release theophylline and/or oral beta 2-agonist,
                                 particularly to control nocturnal symptoms.

                                        If symptoms persist*



     Severe              Inhaled beta2-agonists as needed.
                         Inhaled corticosteroids (higher dose)
                               – With or without cromolyn or nedocromil
                               – With or without extended-release theophylline and/or oral beta 2-agonist,
                                 particularly to control nocturnal symptoms.

                         Oral corticosteroids
                               – Use daily or alternate day schedule.
                               – Reassess often, may need only for short term.

     * Assess if medications are being taken correctly. If not, teach the patient to take medicines correctly.
       When taken correctly, patients may not need to increase their medication.




10
                                                      Asthma Management Component 3: Pharmacologic Therapy




    ENCOURAGE PATIENTS WITH EXERCISE -I NDUCED ASTHMA TO:
    s   Take inhaled beta2-agonist or cromolyn less than 30 minutes before exercising if prescribed.
    s   Warm up and cool down when they exercise.
    s   Exercise in warm humid air or cover the face when the air is cold.
    s   Avoid exercising outside in the afternoon and evening when pollen, mold, or ozone counts are high.
    s   Avoid exercising when asthma is unstable or PEFRs are low.




minutes of vigorous exercise and results in a 15 per-         s   At each visit, ask patients about all medica-
cent or more drop in PEFR or FEV1. EIA usually                    tions they are using, including over-the-
peaks 3 to 12 minutes after stopping the exercise                 counter medications. Ask patients to be sure
and resolves within 30 to 60 minutes. An exercise                 they are NOT taking beta blockers (frequently
challenge helps diagnose the existence of EIA.                    used for high blood pressure, for migraines,
                                                                  and in eye drops for glaucoma). For patients
Emphasize to patients that they should be able to                 sensitive to aspirin, advise them NOT to take
exercise. Ask them to contact their doctor or you if              aspirin-containing drugs and nonsteroidal anti-
their plan to control EIA is not working effectively.             inflammatory drugs (NSAIDs). These drugs
                                                                  can cause severe and even fatal acute asthma
Actions/Implications for Nurses:                                  episodes. Teach patients to read labels carefully
Pharmacologic Therapy                                             and to wear medical alert bracelets. Remind
Asthma Management Plan                                            them that safe alternatives to aspirin and
s   Emphasize long-term ongoing therapy and                       NSAIDs include acetaminophen, sodium
    swift treatment of the early warning signs                    salicylate, or salsalate.
    of an asthma episode (PEFR falls 20 percent               s   Coordinate and integrate for patients the
    below their predicted or personal best or                     different recommendations that may arise
    symptoms occur).                                              when several nurses and physicians are involved
s   Emphasize that patients with moderate                         (e.g., recommendations from primary care,
    and severe asthma need daily inhaled anti-                    pulmonology, allergy, or emergency department
    inflammatory medication to prevent asthma                     staff).
    episodes.                                                 Correct Metered-Dose Inhaler Technique
s   Work with the patient and physician to                    s   Teach the correct techniques for using
    develop a written Asthma Management Plan                      metered-dose inhalers, spacers, and
    tailored to the patient’s needs.                              nebulizers. (Use handouts in appendix D.)
s   At each visit, assess and review each patient’s           s   At each visit, have the patient demonstrate
    use and understanding of his or her Asthma                    the use of medications via the inhaler,
    Management Plan. Review how patients are                      spacer, or nebulizer. Emphasize the impor-
    taking their medicines. (See Patient Education                tance of correct technique and reteach as
    section, pages 12–17, for more details.)                      needed.




                                                                                                                 11
Practical Guide to Asthma Management




Asthma Management Component 4:                               s   Believe they can do it.
Patient Education
                                                             s   Remember to do it.
Nurses play a vital role in helping patients to
decide and learn how to take the many specific               Keep these five factors in mind while working
actions needed to control asthma. These patient              with patients. Use them to help prepare what you
actions are the focus of all asthma patient educa-           will say to patients. Review each handout with the
tion. These actions are listed in table 3 and                questions listed in the box “Questions for Planning
further described in the patient handouts. (See              Patient Education.” Think of your patients as you
appendix D.)                                                 read the questions. Consider making your own
                                                             checklist of key questions to ask patients and points
Additional content should include an explanation
                                                             you want to make. Highlight the key information
of asthma, the goals and principles of asthma
                                                             in the handouts when you speak to patients.
management discussed earlier, and the dangers
of the underuse as well as overuse of medications.           If you prefer fewer questions to use for planning or
Planning Patient Education: Keys to Success                  to discuss with patients, use the following:
What you say and do or omit to say and do will               1. What will make it more likely for the patient
have a significant effect on your patients. Nurses              to take the action?
need to deliberately plan and conduct their patient
                                                             2. What will make it difficult for the patient to
education to increase the chances that their patients
                                                                take the action? How can the difficulties be
will follow the recommended actions. The chances
                                                                reduced?
the recommended actions will be taken increase
greatly when patients:                                       3. What will the patient agree to do?
s    Plan to do the action at a specific time                In addition to working with patients, nurses need
     and place.                                              to build partnerships with patients’ families and
s    Find it easy to do.                                     other health professionals to ensure that support,
                                                             consistent messages, and coordinated care are
s    Benefit from doing it at an acceptable cost and         provided. The results of such partnerships will
     find it helps them avoid serious consequences or        be controlled asthma, fewer sick days, and better
     prevents them from losing something they value.         lives for patients.


     Q UESTIONS     FOR    PLANNING PATIENT EDUCATION

     Plan To Act      What specific action do you want the patient to agree to do? When, where, how, and
                      how often do the patients need to take the action?
     Barriers         How can the action be made easier for the patient to do? How can the medication-
                      taking schedules be adjusted to fit into the patient’s schedule? What patient fears or
                      concerns about asthma and its treatment need to be discussed?
     Benefits         What are the benefits patients would receive and find worth the effort? What do the
                      patient’s family and friends think of the actions and the benefits? What are the conse-
                      quences that are likely to occur and are possibly serious if no action is taken?

     Confidence       What skills training or other help does the patient need to take the action?
     Memory           What will help the patient remember to act?




12
                                                             Asthma Management Component 4: Patient Education




Table 3


    ACTIONS PATIENTS NEED T O TAKE: THE GOALS                         OF   ASTHMA PATIENT EDUCATION
    Objective Measures—Peak Flow Monitoring
          Actions:
          – Take peak flow rate accurately and maintain a daily diary of the rates and asthma symptoms.
          Handout:
          How To Use Your Peak Flow Meter

    Environmental Control
          Actions:
          – Identify and then reduce or eliminate exposure to patient’s triggers.
          Handout:
          How To Stay Away From Things That Make Your Asthma Worse
    Pharmacotherapy
          Actions:
          – Develop a written Asthma Management Plan with the clinician and follow it.
          – Take medications as prescribed.
          – Monitor whether the goals of asthma management are being achieved.
          – Use an inhaler with or without a spacer and/or use a nebulizer correctly.
          – Treat symptoms early and follow the action plan for handling asthma episodes.
          – Call the health care provider when peak flow is below 50 percent of baseline; when breathing,
            walking, and talking are difficult; and/or when medication does not improve the condition.
            (Have a specific written plan for handling emergencies at any time of the day.)

          Handouts:
          Asthma Management Plan
          Your Metered-Dose Inhaler: How To Use It
          Spacers: Making Inhaled Medicines Easier To Take
          How To Use and Care for Your Nebulizer

    Note: Reproducible copies of the patient handouts are in appendix D.



Implementing Patient Education:                                (See appendix C for specific examples of the asthma
Effective Strategies                                           patient education process.)
Help Patients Plan and Take Action
Patients tend to do what they decide is worthwhile             Ask patients what they see as the benefits of a
and what they make specific plans to do. Thus,                 recommended asthma management activity. Ask
patient education is not simply giving patients                about any barriers to their taking the action.
information; it is also assessing their needs and              Involve the patient in finding solutions and
expectations and discussing their response to and              making plans to do the asthma management
decisions about what they are being asked to do.               activities. Get the patient involved by asking
                                                               open-ended questions.




                                                                                                               13
Practical Guide to Asthma Management




                                                         Always convey to patients that you believe they
                                                         will take the recommended action. For example,
                                                         DO NOT say, “If you do . . .”; SAY, “When you
                                                         do . . . .” Tell patients that you know they will
                                                         eventually take the actions and control their asthma.
                                                         Build Confidence: Teach Patients To Do the
                                                         Asthma Management Activities Correctly
                                                         The four R’s—reach agreement, rehearse, repeat,
                                                         reinforce—are the basis for patient teaching. Each
                                                         “R” is described below, and an application of the
                                                         “four R’s” is presented in table 4.
                                                         s   Reach agreement on goals and activities.
                                      Always                 Written action plans and agreements are best.
                                      negotiate a            Agree on:
                                      plan of action
                                      with patients.         – Goals of asthma management.
                                                             – Related personal or family goals.
Always end with a clear plan of action, and obtain
or confirm the patient’s commitment to follow it.            – Actions patients are to perform.
Ask patients to repeat to you what they are to do.
                                                         s   Rehearse the asthma management tech-
Or ask them to tell you how they would explain
                                                             niques. Use the following four steps:
to a family member what they agreed to do. Tell
patients that at the next visit you will assess their        – Describe to patients each step they are to take
asthma and talk about their experience doing these             (e.g., review a handout with patient).
actions.
                                                             – Show patients each step by doing it yourself.
Followup with patients is critical for success.              – Practice—have the patients show you how
At the next visit and each one thereafter, ask                 they do each step. When there are many steps,
patients what agreed-upon actions they took.                   have the patients just do the first three or so
Reinforce their efforts. Then go over the benefits             first, then the next three, and so on.
and barriers and make new plans as discussed above.
                                                             – Give feedback. First, praise patients for
Patients’ readiness to act varies. Some patients               appropriate steps taken, and then gently
you see will be more ready than others to do asthma            correct any missteps. Correct only one error at
management activities. Some may need help                      a time using the steps listed above: describe,
resolving their fears and concerns. Some may need              show, have patient practice, and give feedback.
more time to think about what you have discussed
with them. Ask these patients to think about the         s   Repeat, repeat, repeat.
benefits they are losing or missing by not taking            – Repeat instructions in several ways—orally,
the specific recommended action(s) (e.g., “By not              visually, and in writing.
taking the actions, you are losing the chance to
control your asthma and become symptom-free”).               – Ask patients to repeat the instructions in their
In addition, ask them to talk to family and friends            own words at this AND at subsequent visits.
about the action and its benefits, and possibly to try       – Review when patients are to take the agreed-
the action. Then, follow up with the patient.                  upon actions (e.g., when medications are to
                                                               be taken).


14
                                                             Asthma Management Component 4: Patient Education




Table 4


    ILLUSTRATION        OF THE    FOUR R’S: I NHALER TRAINING
     1. Reach agreement on what the patient is to do when taking inhaled medication—open mouth or
        closed mouth technique or use of a spacer.
     2. Rehearse:

          – Tell the patient the instructions on inhaler use by reading from “How To Use Your Peak Flow
            Meter” (See appendix D) as you show the patient the handout.
          – Show or demonstrate each step for the patient.
          – Practice. Ask the patient to show you how to use the inhaler. (He or she can look at the handout
            while doing this at first.)

          – Feedback. Use the eight steps in the handout as a checklist; check each step that the patient does
            correctly. Then review what steps he or she did well and what needs to be improved. Ask the
            patient to demonstrate the inhaler use again. Remember that the patient does not have to do
            everything correctly after the first instructions.
     3. Repeat. Ask patients to practice what they have
        learned when they use their inhaler. Have them
        show you their technique at subsequent visits.
        Help them with any errors in their technique.
     4. Reinforce. Praise the patients at each visit for
        doing some aspect of the technique correctly or
        just for trying. Express confidence in their ability
        to master the technique. Enthusiastically tell them
        when they get the technique correct.

                                                                 Teach and review inhaler technique at every visit.




    – Ask them to “practice” the technique (e.g.,              The key to success is to generate a feeling of
      inhaler technique) at those times.                       confidence within patients that they can learn and
                                                               do the action. Being critical and demanding before
    – Ask patients to demonstrate (rehearse) their
                                                               the patient has learned the actions can undermine
      peak flow and inhaler techniques at every visit.
                                                               their confidence and your partnership with them.
s   Reinforce.
    – Praise patients who correctly perform ANY
      actions they agreed to do.
    – Recruit the family to remind and praise the
      patient.
Remember that patients often will not do every-
thing correctly after the first instructions. Give
patients time to practice. You might suggest that
they work on one aspect of the action and then help
them with their errors in technique at subsequent
visits.                                                        Give praise at every visit.




                                                                                                                      15
Practical Guide to Asthma Management




Help Patients Remember Your Verbal                         s   Review the contents of the written material
and Written Communications                                     with patients when you give materials to them.
The way you communicate with patients will                     Do not give written information as a substitute
greatly affect how much they remember. Below                   for verbal instruction.
are tips to help you shape your verbal and written
                                                           s   Highlight key points by underlining, circling,
communications so patients better remember them.
                                                               or using a highlighting marker, preferably as
s    Limit the amount of information given at any              you present the information to the patient.
     one time (e.g., do not give a patient extensive           Highlighting key points can enable you to use
     written material, unless the patient requests it.         published material that may be too complex,
     Do not teach peak flow monitoring and how                 contains extraneous information, or has only a
     to use an inhaler for the first time at the same          few sections that you want the patient to pay
     visit, if possible).                                      attention to.
s    Categorize information into three to five             See appendix C for more detailed information
     topics and tell patients these categories before      for conducting patient education at each clinic
     discussing the topics (e.g., “We will talk about      visit.
     three things today: (1) how to use a peak flow
     meter, (2) how to record your peak flow rate,
     and (3) how to interpret the numbers”).               Actions/Implications for Nurses:
                                                           Patient Education
s    Use terms that are familiar to the patient, not
     medical jargon. Use analogies and illustrations       s   Focus on helping patients to decide on,
     relevant to the patient.                                  plan, and take specific actions to control
                                                               asthma. Discuss the benefits, barriers, and
s    Be concrete and specific (specify what to do,             detailed plans for doing each major asthma
     when to do it, and how).                                  management activity.
s    Ask patients how they will remind themselves          s   Put in writing the Asthma Management
     to take the recommended action (e.g., put a sign          Plan, other agreements, and instructions.
     on the refrigerator, do the action with another           Always review and highlight key points in
     daily routine like brushing teeth or eating meals).       preprinted materials.
s    Repeat key points. Ask patients to repeat key         s   Assess patient needs, expectations, and
     points and to tell family and friends what they           satisfaction with their care at each visit and
     have learned. Rehearsal and reinforcement (see
     four R’s on pages 14 and 15) are also important.
Help Patients Understand and Remember
Written Information
The tips listed below are pertinent for all patients,
but they are especially important for patients who
cannot read well.
s    Provide simple, easy-to-read directions for
     asthma management activities that require
     multiple steps. (See handouts in appendix D.)


                                                           Always review written materials with patients.




16
                                                     Asthma Management Component 4: Patient Education




    make needed adjustments. Maintain the                 the action, demonstrate it, ask the patient to do
    partnership with the patient.                         it, and provide feedback to the patient.
s   Make asthma management as easy as pos-            s   Repeat instructions and key points. For
    sible for patients. Adjust medication plans to        example, ask patients to demonstrate their peak
    fit the patients’ schedule, keep recommended          flow and metered-dose inhaler technique at
    actions simple and clear, and limit the amount        every visit.
    of information given at any one time. Ask
                                                      s   Ask patients at the end of each visit to
    about and discuss with patients anything that
                                                          review what specific asthma management
    might interfere with their taking the actions.
                                                          activities they plan to do. At followup visits,
s   Teach and review asthma management                    ask what patients did, reinforce them for their
    actions with patients so they become confi-           effort, correct any problems, or discuss adjusting
    dent and proficient in doing them. Describe           the regimen as needed.




                                                                                                         17
    W ORKING W ITH P ATIENTS F ROM
    D IFFERENT C ULTURAL B ACKGROUNDS



3   Every minority and nonminority group has unique          Within each ethnic or minority group, there is a
    characteristics based on common values, beliefs,         wide diversity of people. Not all people who belong
    practices, race, ethnicity, country of origin, and       to a particular group believe or behave in the same
    language. This section will introduce you to ways        way. Thus, even when nurses are familiar with a
    to develop partnerships for asthma care with             patient’s culture and background, they need to get
    patients from different cultural backgrounds and         to know each individual patient.
    experiences. Table 5 provides a brief practical
    summary of this section.                                 TIPS FOR WORKING WITH PEOPLE FROM
    America has a very diverse population with four
                                                             DIFFERENT CULTURAL BACKGROUNDS
    major minority groups: African Americans,                The following tips will help you establish partner-
    Hispanics/Latinos, Asians and Pacific Islanders,         ships with patients who have cultural backgrounds
    and American Indians and Alaska Natives. Asthma          different from your own.
    is more common and causes more deaths in African         s   Be polite, predictable, somewhat formal, and
    Americans than in the general population. Data               nonconfronting with patients and their family
    on asthma are very limited or absent for minority            members, especially at the first meeting. Treat
    groups other than African Americans; however,                everyone with deference and respect.
    Puerto Rican and Cuban Americans appear to
    have higher prevalence of asthma than whites.

    APPRECIATING INDIVIDUAL PATIENTS
    FROM DIVERSE GROUPS
    Nurses need to acquire a basic understanding of
    their patients’ culture and background and give the
    time and attention needed to ensure accurate and
    smooth communication. Patients will feel grateful
    for the attention, effort, and care given to them.
    In this way, cultural differences can be transformed
    from barriers into bridges to a strong partnership
    for asthma care.
    Open-ended questions asked with genuine interest
    will help nurses learn about the patients’ beliefs
    and practices as well as the community and cultural
    influences on them. This approach will enable
                                                             Nurses can treat patients from diverse backgrounds.
    nurses to provide appropriate care regardless of their
    knowledge of a patient’s culture and background.


    18
                                                   Tips for Working With People From Different Cultural Backgrounds




Table 5


    A CHECKLIST FOR WORKING WITH PATIENTS FROM D IFFERENT
    BACKGROUNDS /C ULTURES
    Formal/Friendly Approach
    s     Use formal address (e.g., Mr., Mrs.) unless patient says otherwise.
    s     Convey respect and genuine interest in the patient.
    s     Ask open-ended questions to learn about patient.
    s     Be nonjudgmental.

    Language Issues
    s     Assess ability to speak English.
    s     See if a family member can read and interpret for the patient.
    s     Provide educational materials in a language and reading level patients can read, if they can read.
          Show patients the key points in the material.

    Family Involvement
    s     Identify who in the family will help the patient.
    s     Involve the family member in developing the treatment plan, if appropriate and the patient
          wants this.

    Medical Practices
    s     Address immediate care needs and then help arrange longer term care (e.g., a primary care doctor,
          transportation, payment).
    s     Learn local/traditional medical beliefs and practices.
    s     Ask patients about “other” things they do for their asthma. Identify the use of traditional and
          home remedies.
    s     Accept/accommodate practices not harmful to patient’s asthma.

    Community Resources
    s     Ask people in the community to interpret for patients, review materials, work as nurses’ aides, or
          obtain additional resources as needed.



   – Use a formal address (Mr. Padilla,                            s   Assess patients’ ability to speak and under-
     Ms. Washington, Mrs. Nguyen) unless told                          stand English. Make provisions for those
     to do otherwise by the patient.                                   who do not speak English well. (See below.)
                                                                       Language is certain to be more of a barrier for
   – Do not make assumptions; ask questions.
                                                                       recently arrived and first-generation Hispanics/
     Observe body language and be responsive.
                                                                       Latinos and Asians and Pacific Islanders.
   – Realize that people from some cultures may
                                                                       – Determine the language in which the patient
     not maintain eye contact with you. This does
                                                                         is most comfortable reading and speaking.
     not necessarily indicate inattentiveness.



                                                                                                                     19
Working With Patients From Different Cultural Backgrounds




     – Learn, at minimum, how to greet non-                      – Ask patients how their family responded to
       English-speaking patients in their own                      their diagnosis and treatment. Ask whether
       language.                                                   someone is telling them something different
                                                                   about their asthma than the doctor or nurse
     – Use an interpreter, if needed (when bilingual
                                                                   did. If there is conflicting information,
       staff members are not available). Find out
                                                                   reassure the patient, and offer to talk to the
       whether family members who speak or read
                                                                   person.
       English can help.
     – Provide bilingual printed materials where             s   Learn about and accommodate traditional
       needed. Remember that fluency in a language               health beliefs and practices relevant to your
       does not guarantee an ability to read in that             patients. Some members of ethnic groups may
       language.                                                 use traditional medicines and healers (e.g.,
                                                                 cuandero, herbalist, spiritualist, root workers) in
     – Use visual aids, especially when there are                combination with mainstream health services.
       language problems.                                        Traditional medicine may significantly influence
                                                                 the patients’ perception of symptoms, decision
s    Involve family members when appropriate. In
                                                                 on when to seek medical care, and adherence to
     general, the most influential people for patients
                                                                 the asthma management plan. To ensure
     will be members of their immediate and ex-
                                                                 effective asthma treatment and control:
     tended family—including grandparents, parents,
     and children. In ethnic communities, family                 – Learn about the beliefs and practices of all
     members are often the source of health-related                patients and of the community where they
     information second only to the clinician. Indi-               reside. For example, visit the community
     viduals who are ill frequently consult family                 and interact with the people; participate in
     members and may ask them to come with the                     cultural events in the area.
     patients on their medical visits.
                                                                 – Assess how the beliefs, practices, and behav-
     – Ask patients whether there is someone who                   iors may interact with the patient’s asthma
       can help them with specific activities (e.g.,               management plan. If a practice is a real
       taking medicines as prescribed, getting to the              threat to the patient’s control of asthma,
       doctor’s office).                                           inform the patient of this fact. Discuss
                                                                   options and then the patient will need to
     – Make sure the waiting room can accommo-
                                                                   decide what to do.
       date patients’ families.


     TWO EXAMPLES         OF   TRADITIONAL HEALING PRACTICES
     A traditional Asian form of healing is “coin rubbing,” which is based on the belief that illness needs to
     be “drawn out” to restore balance in the body. Rubbing produces welts, making it appear that the
     illness has been brought to the surface. Nurses can ask patients about such welts and what they mean to
     them. For patients practicing coin rubbing, it may be useful to say that an inhaled bronchodilator can
     “draw out” the tightness in the chest and wheezing.

     To give another example, some Hispanics/Latinos believe that health conditions are either hot or cold
     and that cold conditions should be treated with hot remedies and vice versa. Asthma is considered to be
     a cold condition. Thus, recommending that the asthma medications be taken with hot herbal teas may
     promote effective asthma management.




20
                                                Tips for Working With People From Different Cultural Backgrounds




    – Accommodate patient and family health                     – Engage and use the services and resources
      beliefs and practices. Undermining tradi-                   of churches, community groups, and local
      tional beliefs only leads to resistance and                 agencies: social services and local sections of
      failure. Fitting new asthma information into                the American Lung Association, Asthma and
      the traditional medicine frame of reference is              Allergy Foundation of America, or Allergy
      far more effective than trying to “educate” the             and Asthma Network. Refer patients to
      traditional beliefs away.                                   support groups and summer camps organized
                                                                  in their communities.
    – Integrate asthma information into the
      patient’s traditional beliefs, practices, and             – Recruit community volunteers to assist you in
      behaviors. See examples below.                              reviewing patient education materials and for
                                                                  interpreting.
s   Locate and use community resources. Many
    ethnic and racial groups have strong and active             – Develop referral lists of physicians with
    community groups and churches that can be                     whom ethnic patients in your area would be
    helpful to patients and nurses.                               comfortable (e.g., bilingual physicians).




                                                                                                              21
    W ORKING W ITH CHILDREN                            AND      A DOLESCENTS




    Specific tips are provided in this section to help             the infant’s physical and emotional needs
    nurses deal with the special needs of children at              predictably. Trust and an environment that fosters


4   different developmental levels. The tips include
    such things as how nurses and parents can effec-
    tively use a nebulizer with infants and toddlers,
                                                                   physical and emotional comfort will make the
                                                                   infant more amenable to asthma management
                                                                   efforts.
    when children are ready to do various self-manage-
    ment tasks, and ways to work with teenagers.                   Tips for Using a Nebulizer With Infants
    How to detect and what to do during an asthma                  Infants can get their medication by nebulizer or by
    episode in infants, toddlers, and preschoolers are             metered-dose inhaler equipped with a spacer and a
    presented in table 6 and the box below.                        mask. Tips for using a nebulizer with infants are
                                                                   listed below.
    INFANTS (0 TO 12 MONTHS)
                                                                   s   Make the nebulizer treatment as pleasant
    Developmental task: trust versus mistrust. Trust is                an experience as possible for all.
    developed when a small number of caregivers meet



         SELECTED T IPS FOR PREPARING PATIENTS TO                  CARE    FOR AN     ASTHMA EPISODE
         IN I NFANTS , T ODDLERS , AND P RESCHOOLERS

         Preparation
         s   Review the indicators of an asthma episode listed in table 6 with the parent(s).
         s   Instruct parents in how to promptly give the prescribed medication, usually with a nebulizer.

         Care During the Episode
         s   Give the prescribed medication.
         s   Make the child comfortable. For infants, adjust their position for maximum chest expansion. For
             toddlers, sitting up or laying down part way may make breathing easier.
         s   Monitor need for fluids. Infants may be given one-quarter of a cup or less of fluids per hour. The
             nipple can be enlarged for easy access. Toddlers may be given one-quarter to one-half of a cup of
             fluids, and preschoolers may be given one-half to one cup per hour. The liquids should be sipped
             slowly. Note: These actions are intended to prevent dehydration. Drinking very large quantities of
             water is not recommended.
         s   Do not give the child food, drink, or medications that are not well tolerated. Usually, the child
             should NOT drink hot or cold liquids, drink quickly, or eat solid foods. Teach the family which medica-
             tions may irritate the stomach and how to take them, if necessary.




    22
                                                                                                                      Infants (0 to 12 months)




Table 6


    INDICATORS          OF   PROBLEMS WITH A STHMA                        IN       INFANTS       AND   CHILDREN *
                                                      Toddlers             Preschoolers                  6 to 12                 12 to 17
     Measure                    Infants          (1 to 3 years old)      (3 to 5 years old)             years old                years old

     General                 Fussy, lethargic,   Lethargic, not        Does not respond           Can say how they          Determine if
     responsiveness          unresponsive,       active.               normally to play or        feel but may be           behavior is
                             irritable.                                stimulation.               breathless.               different from
                                                                                                                            usual.

     Ability to eat,         Stops feeding       May refuse to eat     May stop eating            Cannot keep up with       Poor appetite,
     sleep, play             to breathe.         or drink; may         solids, decrease           others their age,         broken sleep, or
                             Sleep altered by    cough and vomit;      fluid intake, vomit        absent from school        not involved with
                             cough.              sleep and play        with coughing, or          due to asthma, avoids     peers. History can
                                                 disrupted.            complain of                “gym,” physical           tell if problems are
                                                                       stomachache.               activity.                 asthma related.

     Quality of voice        Shorter, softer     Effort to breathe     Has trouble                Cannot speak one          Cannot speak one
                             cry.                may affect voice.     speaking several           or two full               or two full
                                                                       words together.            sentences without         sentences without
                                                                       May be hoarse or           breathlessness.           breathlessness.
                                                                       wheezy.

     Respiratory             Cough increases,    Cough at night may    Sits quietly, breathing    Should be able to         If able, ask to walk
     symptoms                especially when     indicate developing   hard, wheezing, or         describe symptoms         or jog up corridor
                             lying down.         episode. Listen to    coughing. Have walk        and what happened         or stairs and
                             May wheeze.         parents for           around and observe         in past episodes.         observe response/
                             Retractions may     symptoms of past      response.                                            symptoms.
                             be evident.         episodes.

     Color                   Pale to cyanotic. Pale, dark circles      Pale, dark circles         Pale, dark circles        Pale, dark circles
                                               under eyes,             under eyes, cyanotic.      under eyes, cyanotic.     under eyes,
                                               cyanotic.                                                                    cyanotic.

     Respiratory rate        >35 breaths         >25 breaths per       >25 breaths per min.       >23 breaths per min.      >20 breaths per min.
     at sleep (approx.)      per min.            min.                                             (for 6- to 8-year-olds)
     indicating
     problems

     Respiratory rate     >85 breaths            >46 breaths per       >41 breaths per min.       >23 breaths per min.      >20 breaths per min.
     when awake           per min.               min.                                             (for 6- to 8-year-olds)
     (approx.) indicating
     problems

     Heart rate, normal      80–200 beats        70–120 beats per      60–110 beats per min.      60–90 beats per min.      50–90 beats per min.
     range–sleeping          per min.            min.

     Heart rate, normal      80–200 beats        80–150 beats per      70–150 beats per min.      70–110 beats per min.     55–100 beats per
     range–awake             per min.            min.                                                                       min.

    *NOTE: A comprehensive assessment of the child and clinical judgment are required in evaluating children. This table gives only
           guidelines for assessment. Also, parents may not know all the times their child had symptoms.




s   Identify what activities soothe the infant                                      set the machine on a rug or towel, or play soft
    and when the infant is likely to accept                                         music near the infant.
    treatments—such as after meals, before naps,
                                                                               s    Limit treatments to 10 minutes.
    or at bedtime.
                                                                               s    Prop or seat the infant at an angle of 45
s   Minimize the noise from the nebulizer, if it
                                                                                    degrees or more. Some nebulizers will not
    bothers the infant. Move the nebulizer farther
                                                                                    mist if the infant is lying down.
    away by attaching longer tubing (up to 20 feet),


                                                                                                                                                   23
Working With Children and Adolescents




s    Don’t use a mask strap, which may feel too              s   Establish a treatment time in a way the
     tight or restrictive. If the child will not tolerate        toddler can understand. Prepare the toddler
     a mask, cup your hand over the infant’s nose to             by telling him or her that, for example, at the
     make a “hand mask,” which may be better                     next commercial or when the timer goes off, it’s
     tolerated.                                                  time for the medicine. Tell the toddler that
                                                                 the treatment will last until the timer goes off
s    Remember that infants’ skin tends to be
                                                                 again, the program ends, or the story is over.
     sensitive. Wash the infant’s face after treat-
     ment or cover it with a barrier cream (such as          s   For the toddler who will not tolerate sitting
     a petroleum ointment) before treatment if the               for the entire treatment:
     infant’s face breaks out in a rash or becomes red.
                                                                 – Have the toddler take five to seven
                                                                   “practice” deep breaths using the nebu-
TODDLERS (12 TO 36 MONTHS)                                         lizer. If the treatments are a struggle and
Developmental task: autonomy versus shame and                      the child is not in distress, stop the
doubt. Toddlers believe they are the “boss.” Their                 treatment. The treatment will not be
favorite word is “no.” Their body language and                     finished, but a positive, cooperative environ-
actions match. Their ability to make themselves                    ment will be established.
understood is limited. Parents and care-givers must
                                                                 – Use a timer, setting it for increasing lengths
remember that when a toddler says no, it does not
                                                                   of time to help the toddler develop tolerance.
always mean no. It may mean yes, not right now,
or I don’t know. Nurses must work with the family                – Consider using a metered-dose inhaler
to understand the unique personality traits of the                 with a spacer and face mask. This may be
toddler and to help the family participate in the                  a good alternative for the toddler who will
partnership for asthma care.                                       take five to six breaths on command. A
                                                                   metered-dose inhaler with spacer and face
                                                                   mask has been shown to be as effective in
                                                                   delivering medication as a nebulizer.

                                                             Tips for Giving Oral Medications to Toddlers
                                                             s   Remember: The fact that an adult wants
                                                                 the toddler to take the medicine may be the
                                                                 very reason the toddler refuses. Tell the
                                                                 toddler, “I’m giving you some medicine to help
                                                                 you breathe (feel) better.” Assume the toddler
                                                                 will take the medicine and say, “Would you like
                                                                 a piece of fruit or juice after your medicine?”
Tips for Using a Nebulizer With Toddlers                     s   Praise the toddler for efforts to take the
s    Involve the toddler in pleasant experiences                 medicine.
     during and after treatment. Select a special
     area and activity to take place only during
                                                             s   Taste the medicine yourself. Disguise the
     treatments. Give the toddler a used mask setup              medicine as necessary in a small amount of
     to put on a favorite bear or doll. After the                strong but good-tasting food (such as plums),
     treatment, let the toddler choose a reward, such            but do not mix the medicine with a meal or in a
     as brushing teeth (toddlers love water), having a           whole glass of liquid. Have the toddler suck a
     snack (e.g., a favorite fruit), or watching a special       lollipop or brush his or her teeth before taking
     television program.


24
                                                                             Preschool Children (3 to 5 Years)




  the medicine to minimize the taste; but never          with things that may be difficult for them to do
  call the medicine candy.                               consistently. Help parents understand the unique
                                                         personality traits and capabilities of their preschool
Tips for Preparing the Toddler To Use Peak               child in encouraging the partnership for asthma care.
Flow Meters and Metered-Dose Inhalers
Have the toddler practice “blowing out” with             Preschool children often ask questions about
party favors (preparation for peak flow meter)           asthma and their medication (e.g., “Why do I have
and “breathing in slowly” with straws (preparation       to take medicine?”) but need only basic answers
for metered-dose inhaler). Use the same words to         (e.g., “to help you with your cough,” “to help
reinforce a job well done. Call the toddler’s lungs      you breathe”). The concepts of lungs, mucus,
“air balloons” to help the toddler understand “in        and airways are difficult for a preschool child to
and out.” Do not teach the use of a peak flow            understand.
meter and an inhaler at the same time. Teach the
                                                         Begin teaching about what makes the child’s
proper use of the inhaler first.
                                                         asthma worse and how to avoid or manage
                                                         exposures. Preschool children may, for the first
PRESCHOOL CHILDREN (3 TO 5 YEARS)                        time, spend much of their time outside the home
Developmental task: initiative versus guilt.             and encounter such triggers as smoke, pets, chalk
Preschool children are moving into a larger social       dust, and upper respiratory infections. Asthma
environment and beginning new activities. They           episodes may increase. The goal is to avoid or
are verbal and can participate in their care,            manage exposures to prevent such episodes.
although reasoning is rudimentary, problem solving
is intuitive rather than logical, and thinking remains   Tips for Training Preschoolers To Use Inhalers
egocentric. Nurses must also help families recognize     and Peak Flow Meters
that the preschooler needs to, wants to, and has         Preschool children are becoming better able
to have opportunities to act independently.              to use peak flow meters and metered-dose
                                                         inhalers with spacers. Once preschool children
                                                         are approximately 3 feet tall, the standard charts
                                                         of predicted peak flow rates can be used. Once
                                                         the child can reliably use the peak flow meter, an
                                                         objective personal best can be established. (See
                                                         patient handout in appendix D.)
                                                         First, train preschoolers to use an inhaler with a
                                                         spacer. After 1 to 2 months, train them to use a
                                                         peak flow meter. It is too confusing for the child
                                                         to learn both techniques at the same time. Ensure
                                                         that the preschool child has adequate time to
                                                         learn the new techniques and receive adequate
                                                         medication by doing the following:
Keep lines of communication open so problems
can be identified and solved. Children as young
                                                         s   Give just the midday treatment with the
as 4 may be aware of their “difference” due to               inhaler when starting the training. Continue
asthma, and their behavior may reflect this—not              with morning and evening nebulizer treatments.
wanting to take medicine, play outside, sleep. At        s   After 1 to 2 weeks, change completely to
each visit, ask parents about their children’s activi-       an inhaler—if asthma symptoms are well
ties and provide support or solutions to help children       controlled day and night.



                                                                                                           25
Working With Children and Adolescents




s   Young children can learn how to use a peak flow      The many issues that arise from the school-age
    meter by blowing into a party favor and making       child’s separation from parents require sensitivity.
    it unroll and make noise.                            Nurses need to help families understand the
                                                         school-age child’s need for independence and foster
s   Use a sticker chart for reinforcement for
                                                         the child’s ability for self-care within the partner-
    using the inhaler and/or peak flow meter.
                                                         ship for asthma management.
    Preschool children love stickers and like being
    able to select one to put on their own chart after   To assist the school-age child with asthma, it is
    each treatment. Additional reinforcement can         important to:
    be given at the end of a particular time period
    (such as every week).                                s   Start preparing the child for independent
                                                             self-care. Depending on the child’s comfort
                                                             level, begin seeing the child alone at the start of
SCHOOL-AGE CHILDREN (6 TO 12 YEARS)                          a visit. (Explain to parents why their child is
Developmental task: industry versus inferiority.             being seen alone before doing so.) Discuss the
The major task of the school-age child is to learn           goals of asthma management and the treatment
and achieve independence. A school-age child is              plan. Then have the parent come into the room
inquisitive, engaging, conscious of peers, influenced        and have the child explain or help you explain
by adults other than parents, and involved in                the key points. This helps establish rapport and
outside-the-home activities. In addition, positive           tells children that they are “grown up,” taken
reinforcement for reaching physical potential and            seriously, and responsible for the care of their
emphasizing other strengths are valuable in the              asthma. Having parents observe such attention
child’s development.                                         increases their confidence in the child’s ability
                                                             to master self-care.
                                                         s   Work with school-age children so they can
                                                             manage their asthma episodes. Ask about
                                                             and discuss signs and symptoms the child has
                                                             before and during an asthma episode. (See table
                                                             6.) Actively involve the child in deciding what
                                                             to do. Explain when the child should contact
                                                             parents, nurses, doctors, and/or other helpful
                                                             adults.
                                                         s   Address the four components of asthma
                                                             management. (See section 2, “Practical Guide
                                                             to Asthma Management,” for details.)
                                                             – Peak flow monitoring. Check children’s
                                                               peak flow meter techniques often and review
                                                               their peak flow diary, if used, at each visit.
                                                             – Environmental control. Make sure school-
                                                               age children recognize their asthma triggers
                                                               and that appropriate actions are being taken
                                                               to control them. When episodes occur, help
                                                               children identify what set off the episode and
                                                               what they could do differently next time to
                                                               prevent an episode.



26
                                                                                 Adolescents (13 to 17 years)




    – Medications. Assess whether children know         ADOLESCENTS (13 TO 17 YEARS)
      the difference between their medications,         Developmental task: identity and intimacy versus
      when to take them, how to take them, and          confusion and isolation. The process of identity
      the possible side effects.                        formation begins in early adolescence when the
    – Patient education. In addition to the issues      individual’s interest is focused on peer group
      listed above, assess children’s understanding     activity. The peer group defines acceptable and
      of asthma and clarify any fears or misconcep-     unacceptable behavior and through the peer
      tions. At each visit, ask children to demon-      group, adolescents try to demonstrate they are
      strate their inhaler technique and ask when       “doing their own thing.” Authority in general
      they are taking their medications. Devise         may be viewed with skepticism. Adolescents tend
      ways with the child and parents to remind         to be self-conscious, believing that other people
      them to take the medication at the times          are constantly evaluating their appearance and
      prescribed.                                       behavior.

s   Evaluate whether the child is taking his or
    her medication appropriately by asking the
    child and parents separately about how often
    and how much is taken. If adherence with the
    treatment plan is a problem, suggest that the
    child (or the parents) monitor the medication
    taking by keeping a medication diary. Reinforce
    adherence to the regimen.
s   Tell school-age children that they can or
    will be able to participate in activities other
    children their age do, when their asthma is
    properly managed. Let children with asthma
    know that some Olympic athletes have asthma.
    Put a poster of these athletes in your office.
                                           .
    (Order poster #NN504 from NAEPP See page            Adolescents receiving proper care usually proceed
    35 for address.)                                    through their adolescent years with only minor
                                                        problems due to asthma. However, some adoles-
s   Encourage parents to be advocates for the
                                                        cents with asthma may rebel against all constraints
    child at school. One of the goals of therapy for
                                                        and refuse medication and treatment.
    a school-age child with asthma is to achieve full
    participation in all school activities, including   Nurses must work together and individually with
    sports. A team meeting with parents and school      adolescents and parents to promote the partnership
    personnel may help to delineate rules for school    for asthma care. Be careful not to get caught in
    attendance and special needs for tutorial or        the middle between a parent and an adolescent
    physical education programs. Plans for han-         who are not communicating.
    dling asthma episodes at school also need to be
    developed and written.                              Tips for Getting Adolescents’ Attention and
                                                        Building a Partnership
s   Encourage the school-age child to attend a          s   Talk to adolescents as adults.
    local asthma camp. Call the local American
    Lung Association affiliate to find local camps.     s   Find out from the adolescent how asthma
                                                            has affected his or her activities.



                                                                                                         27
Working With Children and Adolescents




s    Review management of episodes at each         Tips for Identifying Problems and Negotiating
     visit. Ask about asthma episodes and          the Asthma Management Plan
     symptoms that occurred since the last visit   s   Conduct well-planned nursing assessment
     and the actions taken to control them.            interviews with adolescents. (See appendix C,
                                                       for example.) Absence from school and sports
s    Focus on immediate benefits and conse-            and peer issues also can be assessed.
     quences.
                                                   s   Negotiate an agreement with the patient
s    Help the adolescent to be responsible and
                                                       using the Asthma Management Plan (see
     successful in keeping his or her asthma
                                                       handout in appendix D) as a guide.
     under control. Follow the patient education
     recommendations in this guide and treat       s   Make sure adolescents have immediate
     adolescents as adults.                            access to their medications. Contact the
s    Involve parents in the care while maintain-       school about medication policy, if needed.
     ing the focus on the adolescent.              s   Refer adolescents who continue to have
                                                       problems managing their asthma to self-
                                                       management programs and support groups,
                                                       especially those with other adolescents.




28
WORKING WITH A DULTS                          AT      DIFFERENT AGES




In this section, issues related to all adults with         s   Environmental control. Ask patients about
asthma will be presented first. Then issues relevant           things that make their asthma worse and what
to younger and older adults will be addressed                  they do to avoid or reduce exposure.
briefly.                                                   s   Medications. Make sure the patient knows
                                                               about his or her medications, when to take
TIPS FOR WORKING WITH ADULTS                                   them, how to take them, and their possible side
In teaching and communicating with adults of all
ages, remember these principles of adult learning:
                                                               effects. Have patients show you their technique
                                                               with the metered-dose inhaler, spacer, and/or
                                                                                                                    5
                                                               nebulizer.
s   Adults want to learn when they experience needs
    that can be satisfied through learning. Stimulate      s   Patient education. In addition to the issues
    the desire to learn through patients’ desire for the       listed above, assess patients’ execution of their
    benefits of having their asthma under control              asthma management plans. Reach agreement
    (e.g., able to exercise, not miss work or school,          on needed actions, rehearse, repeat, and rein-
    sleep through the night, feel good).                       force.
s   Adult orientation to learning is life centered.
    Solve asthma care problems in terms of effect          SPECIAL CONSIDERATIONS FOR YOUNG ADULTS
    on lifestyle.                                          s   Pregnancy issues. Asthma control is particu-
                                                               larly important. An adequate supply of oxygen
s   Experience is the richest resource for adult
                                                               for the fetus must be maintained. The risks of
    learning. Build on the asthma patient’s experi-
                                                               uncontrolled asthma to the pregnant patient
    ence. Discuss, use case studies, act out situations.
s   Adults have a deep need to be self-directing or
    independent. Actively involve adults in develop-
    ing their own asthma care plans.
Issues To Address With All Adults With
Asthma. For all adults with asthma, nurses should
assess whether the patient is meeting the goals of
asthma management and review and reevaluate the
written plan of care based on the four components
of asthma management. (See section 2, page 4 for
details.)
s   Peak flow monitoring. Review patients’ peak
    flow meter technique and their PEFR diary.
    Discuss how they use their PEFRs.


                                                                                                               29
Working With Adults at Different Ages




     and her fetus are far more dangerous than the          these changes in a variety of ways, including the
     risks from the medications to control asthma.          following:
     (See the National Asthma Education and
                                                            – Make sure treatment plans are as simple as
     Prevention Program publication “Executive
                                                              possible.
     Summary: Management of Asthma During
     Pregnancy” on page 35.)                                – Use short written explanations with simple
                                                              graphics.
s    Issues surrounding the inheritability of
     asthma. The tendency to develop allergies is           – Provide instructions for medications in larger
     inherited. Allergies increase the chances of             typeface and use color-coded peak flow meter
     developing asthma.                                       diaries.
                                                            – Speak in a low-pitched voice with adequate
SPECIAL CONSIDERATIONS FOR OLDER ADULTS                       volume for the patient to hear easily.
(AGE 65 AND OVER)
                                                            – Increase lighting levels.
Older adults with asthma have decreased maxi-
mum breathing capacity, vital capacity, inspiratory         – Have the patient read and then repeat
reserve volume, and oxygen-diffusing capacity.                instructions.
Older adults may also be affected by normal
                                                            – Allow time for both demonstration and
physiologic changes in other body systems (such
                                                              redemonstration of inhaler and peak flow
as vision loss and decreases in gastrointestinal
                                                              meter techniques.
absorption and muscle strength) and by coexisting
diseases (such as stroke, arthritis, and chronic        s   Monitor the use of nonasthma medications
obstructive pulmonary disease).                             such beta blockers, aspirin, and nonsteroidal
                                                            anti-inflammatory drugs (NSAIDs) that can
To be responsive to older adults, nurses need to do         cause asthma episodes.
the following:
                                                        s   Identify and be responsive to psychosocial
s    Be sensitive and accommodating to neuro-               changes such as disruptions in lifestyle caused
     logic changes (such as slowed or altered sensory       by loss of spouse, loss of family members and
     responses, memory loss, decreased sense of             friends, loss of financial independence, and
     balance and fine motor movement, and hearing           retirement.
     and vision losses). Nurses can be responsive to




30
SPECIAL CONSIDERATIONS                     FOR        SURGERY      AND

GASTROESOPHAGEAL REFLUX PATIENTS




SURGERY                                                  therapy. Symptoms in infants and young children
Patients with asthma who must undergo surgery            include excessive belching, burping, spitting up,
are predisposed to intraoperative and postoperative      and fussiness.
respiratory complications. Prior to any surgery, a       The medical management of gastroesophageal
complete assessment of the patient must be made,         reflux includes:
and the patient’s lung function optimized. Tech-
niques are described in the section on surgery and       s   Not eating or drinking for 3 hours before
asthma in the NAEPP Guidelines for the Diagnosis             retiring—or before lying down, for example,
and Management of Asthma. (See NAEPP materials,              on the floor or couch to watch television.
page 35.)                                                s   Elevating the head of the bed 6 to 8 inches

GASTROESOPHAGEAL REFLUX
                                                             (blocks of wood can be used). Keep infants
                                                             upright.
                                                                                                                 6
A significant proportion of patients with asthma         s   H2 receptor antagonists (such as cimetidine,
experience gastroesophageal reflux—the return of
                                                             ranitidine, famotidine).
stomach contents into the esophagus. Reflux may
increase asthma symptoms, and reflux may occur           If the patient is taking theophylline, which de-
at any age. However, the extent to which gastro-         creases lower esophageal sphincter pressure, the
esophageal reflux contributes to asthma symptoms         clinician may consider switching to other medica-
is controversial.                                        tions or try reducing the serum theophylline level
                                                         to under 10 µg/mL. The clinician may also refer
Symptoms of gastroesophageal reflux in older
                                                         the patient to a gastroenterologist.
children or adults include belching, heartburn, and
nighttime asthma episodes that do not respond to




                                                                                                            31
    RESOURCES TO MEET PATIENTS’ NEEDS




    Nurses need to emphasize to patients with asthma         s   This medication costs $__. Do you have to pay
    that when asthma is under control and when                   for it? Do you have to pay up front and get
    triggers are eliminated or lessened in the environ-          reimbursed? Does it cost less at a wholesale
    ment, the costs of asthma are also lessened.                 pharmacy? Do you need to send away for your
                                                                 prescription medications?
    FINANCIAL ASSISTANCE                                     s   Do you have to contact your primary health care
    Options for financing health care for asthma                 provider before you make clinician appoint-
    include health insurance, government-sponsored               ments? Arrange for lab work or x-rays? Go to
    programs, and services furnished by voluntary                the emergency department?
    organizations. Patients and their families may also
    find assistance—or prices better matching their          In addition, see if your patients can be enrolled
    income level—through contacting:                         into asthma case management programs offered by
                                                             some preferred provider organizations and other
    s    The office of social services in the medical        insurers.
7        facility where the asthma patient is receiving
         treatment or care.                                  Government-Sponsored Programs
    s    The primary care or health care provider.           The Federal and State government programs that
                                                             provide financial assistance for asthma care (includ-
    s    The agent or claims representative of their         ing medications and equipment) include:
         health insurance company.
                                                             s   Medicare.
    s    The billing department for a specific health care
         provider or medical facility.                       s   Medicaid.

    s    Their State department of health and welfare.       s   Hill-Burton Program.
                                                             s   Department of Veterans Affairs (VA).
    Health Insurance
    Many patients and their families have health             s   Civilian Health and Medical Programs of the
    insurance through employers or as individuals.               Uniformed Services (CHAMPUS).
    Patients need to know what is covered, if asthma is      s   Children with special needs programs.
    a preexisting condition excluded from coverage,
    and if any preapprovals are needed. Issues that          s   Pharmacy assistance programs.
    nurses may need to explore with patients include
                                                             Voluntary Organizations Assistance
    the following:
                                                             Service and community organizations often provide
    s    A nebulizer costs $__ in this area. Will your       assistance, although not necessarily direct financial
         insurance cover this cost?                          aid. Among these organizations (most of which are
                                                             listed under “Social Service Organizations” in the


    32
                                                                              Actions/Implications for Nurses




yellow pages directory) are the Salvation Army,
United Way, Lutheran Social Services, Jewish Social    Actions/Implications for Nurses:
Services, and Associated Catholic Charities as well    s   Be familiar with the real costs of asthma care to
as local churches, synagogues, and professional            patients in your community, including costs of
women’s organizations. The Kiwanis, Knights of             asthma medicines, equipment, and equipment
Columbus, Elks, and Moose lodges may also be               rentals.
helpful, particularly if a family member belongs to    s   Encourage patients and parents to express any
the organization.                                          concerns about the financing of asthma care.
Health Care and Equipment Providers                    s   Be aware of community resources to help meet
Health care professionals are aware of the economic        the financial needs of asthma patients. These
burden of asthma care and may be able to devise            may include drug programs for people with low
ways to reduce costs or extend payments over a             income, social services, State and local health
longer period of time. In addition, local medical          departments, and voluntary organizations.
schools may provide free or low-cost care.
                                                       s   Be familiar with the coverage of asthma care
Patients with asthma and their families may need           that various health insurance policies and
to apply for financial aid. They may need to               government-sponsored programs provide before a
explain their financial situation to, for example, a       treatment plan is worked out with the patient.
hospital’s business office or social work depart-
ment, the physician, or an equipment company.
Sliding scales for payments based on income and
need—for which the patient or family must ask
consideration—may be available.




                                                                                                          33
    SOURCES           OF     ASTHMA INFORMATION                       AND      MATERIALS




    SOURCES OF PATIENT EDUCATION MATERIALS                        s   State Medicaid Directors Association, Affiliate of
    AND AIDS FOR NURSES                                               the American Public Welfare Association, 810 First
    Inclusion in this list does not indicate endorsement by           Street, N.E., Suite 500, Washington, DC 20002-
    the National Heart, Lung, and Blood Institute.                    4205 (202-682-0100) (http://medicaid.apwa.org).
    Information was accurate at the time of printing.                 (Note: Maintains a directory that lists State
                                                                      Medicaid directors.)
    s   American Academy of Allergy, Asthma, and
        Immunology, 611 East Wells Street, Milwaukee,             s   National Association of Insurance Commission-
        WI 53202 (414-272-6071) (www.aaaai.org).                      ers, 120 West 12th Street, Suite 1100, Kansas City,
                                                                      MO 64105 (816-842-3600) (www.naic.org).
    s   American College of Allergy, Asthma, and                      (Note: Maintains a directory that lists State
        Immunology, 85 West Algonquin Rd., Suite 550,                 insurance commissioners. The State commissioners
        Arlington Heights, IL 60005 (847-427-1200)                    regulate insurance sold in their State.)
        (www.allergy.mcg.edu).
    s   American Lung Association (ALA). Use the                  SELECTED RESOURCE PUBLICATIONS
        telephone directory to find your local ALA affiliate.     s   Children With Asthma, by T.F. Plaut, M.D.
        If you need assistance in finding the affiliate nearest       Available from: Pedipress, 125 Red Gate Lane,
        to you, contact the national office at: 1740                  Amherst, MA 01002 (800-611-6081)
        Broadway, New York, NY 10019 (800-                            (www.pedipress.com). A paperback guide.

8   s
        LUNGUSA) (www.lungusa.org).
        Allergy and Asthma Network/Mothers of
                                                                  s   One-Minute Asthma—What You Need To Know
                                                                      (also available in Spanish), by T.F. Plaut, M.D.
        Asthmatics, Inc., 2751 Prosperity Avenue, Suite               Available from: Pedipress, 125 Red Gate Lane,
        150, Fairfax, VA 22031-4397 (800-878-4403)                    Amherst, MA 01002 (800-611-6081)
        (www.aanma.org).                                              (www.pedipress.com).
    s   Asthma and Allergy Foundation of America                  s   Peak Flow Meters: A Thermometer for Asthma.
        (AAFA), 1125 15th Street, N.W., Suite 502,                    Available from: American Academy
        Washington, DC 20005 (800-7-ASTHMA)                           of Allergy, Asthma and Immunology, 611 East
        (www.aafa.org).                                               Wells Street, Milwaukee, WI 53202 (414-272-
    s   National Asthma Education and Prevention                      6071) (www.aaaai.org).
        Program, National Heart, Lung, and Blood                  s   Standardization of Spirometry—1994 Update—
        Institute (NHLBI) Information Center, P.O. Box                Recommendations on how to do spirometry.
        30105, Bethesda, MD 20824-0105                                Available from: American Thoracic Society, 1740
        (www.nhlbi.nih.gov).                                          Broadway, New York, NY 10019 (212-315-8700)
    s   National Jewish Medical and Research Center,                  (www.thoracic.org).
        1400 Jackson Street, Denver, CO 80206 (800-
        222-LUNG) (www.njc.org). (Provides care for very
        severe asthma patients and operates an information
        service staffed by nurses.)

    34
                                                                                              NAEPP Materials




s   Asthma Care and Patient Education: The             s   Parent advocacy groups—Listed yearly in
    Nurses Role. Available from: Asthma and                Exceptional Parent Magazine or with the National
    Allergy Foundation of America, Suite 502, 1125         Information Center for Children and Youth With
    15th Street, N.W., Washington, DC 20005                Disabilities, P.O. Box 1492, Washington, DC
    (www.aafa.org). OUT OF PRINT JANUARY                   20013-1492 (800-695-0285) (www.nichcy.org).
    1999
s   You Can Control Asthma—Easy-to-read                NAEPP MATERIALS
    material for children. Available from: Asthma      The following publications are available from
    and Allergy Foundation of America, Suite 502,      the National Asthma Education and Prevention
    1125 15th Street, N.W., Washington, DC 20005       Program (NHLBI Information Center, P.O. Box
    (800-7-ASTHMA) (www.aafa.org).                     30105, Bethesda, MD 20824-0105)
                                                       (www.nhlbi.nih.gov).
s   Your Child and Asthma. Available from:
    National Jewish Medical and Research Center,       s   Practical Guide for the Diagnosis and Man-
    1400 Jackson Street, Denver, CO 80206 (800-            agement of Asthma (1997) (60 pages).
    222-LUNG) (www.njc.org).
                                                       s   The Role of the Pharmacist in Improving
s   Open Airways For Schools—A school-based                Asthma Care (1995)—This guide details six
    asthma health education program for children           specific ways a pharmacist can increase patients'
    with asthma. Available from: Local affiliates of       understanding of asthma and its treatment (10
    the American Lung Association, 1740 Broadway,          pages).
    New York, NY 10019 (800-LUNGUSA)
    (www.lungusa.org).
                                                       s   Teach Your Patients About Asthma: A
                                                           Clinician’s Guide (1992)—Patient education
s   Health Care Financing: A Guide for Families            guide that includes teaching notes and patient
    (1988), by Julianne Beckett. Available from:           handouts (98 pages).
    National Maternal and Child Health Resource
    Center, College of Law/University of Iowa, Iowa
                                                       s   Facts About Controlling Your Asthma
    City, IA 52232 (319-335-9073). OUT OF                  (1997)—An overview of asthma (also available in
    PRINT JANUARY 1999                                     Spanish) (12 pages).

s   Understanding Your Health Insurance Op-
                                                       s   Your Asthma Can Be Controlled: Expect
    tions, by Margaret McManus. Available from:            Nothing Less (1992)—A pamphlet for patients
    Association for the Care of Children’s Health,         with asthma (20 pages).
    7910 Woodmont Avenue, Suite 300, Bethesda,         s   Asthma and Physical Activity in the School
    MD 20814, (301-654-6549). OUT OF PRINT                 (1995)—For teachers and coaches who want to
    JANUARY 1999                                           help students with asthma participate in sports
s   Title XIX State Agency and HCFA Regional               and physical activities (18 pages).
    Office Directory (1987). For patients and          s   Making a Difference...Asthma Management in
    nurses: This free directory defines all Medicaid       the School (1994)—A 13-minute videotape
    and Federal health finances in their various           designed to improve understanding and manage-
    programs. Available from: Office of Intergov-          ment of asthma in school settings.
    ernmental Affairs, HCFA (Health Care Financing
    Administration), Room 403-B, Hubert H.             s   Asthma Awareness Curriculum for Elementary
    Humphrey Building, 200 Independence Avenue,            School (1993)—Two 30-minute lessons help
    S.W., Washington, DC 20201. OUT OF PRINT               students understand and accept classmates who
    JANUARY 1999                                           have asthma.
                                                       s   Managing Asthma: A Guide for Schools
                                                           (1991) (17 pages).




                                                                                                               35
    APPENDIX A

    DOSAGES             AND      SIDE EFFECTS          OF     MEDICATIONS
    FOR     CHRONIC ASTHMA


    Anti-inflammatory medications. Anti-inflammatory medications prevent swelling and narrowing of the
    airways. To effectively manage chronic asthma, these medications need to be taken every day whether
    asthma symptoms are present or not.

    Medication          Dosage                 Side Effects                 Comments/Tips

    Nonsteroidal
    Anti-inflammatory
    Medications
    Cromolyn sodium     Metered-dose inhaler   Rare.                        Comments
                        2 puffs bid–qid        Cough or throat irritation   Used to prevent asthma symptoms and episodes.

                        Nebulizer solution                                  Need to use for 4 to 6 weeks to determine if
                        1 ampule (20 mg)                                    there will be a positive effect.
                        bid–qid
                                                                            Can be taken 5 to 60 minutes before exercise
                                                                            or contact with asthma trigger to prevent
                                                                            symptoms. Effects last 3 or 4 hours.

                                                                            Will not provide immediate relief of symptoms
                                                                            during an asthma episode. During an episode,
                                                                            patients should use a bronchodilator first but
                                                                            also continue their regular schedule of cromolyn.

                                                                            Tips
                                                                            Drink water before and after use to avoid dry
                                                                            cough. The canister holding the medicine should
                                                                            not be put in water.

A   Nedocromil sodium 2 puffs bid–qid          Rare.                        Comments
                                               Headaches, nausea,           Used to prevent asthma symptoms and episodes.
                                               vomiting, cough,
                                               unpleasant taste             Recommended for adults and children 12 years
                                                                            or older.

                                                                            Will not provide immediate relief of symptoms
                                                                            during an asthma episode. During an episode,
                                                                            patients should use a bronchodilator first
                                                                            but also continue their regular schedule of
                                                                            nedocromil.

                                                                            Tips
                                                                            Rinse the mouth with water or brush teeth
                                                                            after use to decrease unpleasant taste.
                                                                            Canister should not be put in water.




    36
                                                 Dosages and Side Effects of Medications for Chronic Asthma




Medication        Dosage              Side Effects               Comments/Tips

Steroidal Anti-
inflammatory
Medications
Inhaled           Children            Throat irritation,         Comments
corticosteroids   Moderate–Severe     yeast infection in the     Used to prevent asthma symptoms and episodes.
                  2–4 puffs bid–qid   mouth, occasional cough,
                  (168–672 mcg)       difficulty or pain in      Children as young as 3 years of age can use
                                      speaking                   inhaled corticosteroids if a holding chamber or
                  Adults                                         spacer device is attached to the inhaler.
                  Moderate Asthma
                  2–4 puffs bid                                  Children with moderate asthma are usually given
                  (168–336 mcg)                                  an initial trial of cromolyn sodium. Then inhaled
                                                                 steroids are introduced, if needed.
                  Adults
                  Severe Asthma                                  Concentration per inhalation varies:
                  2–6 puffs bid–qid                              beclomethasone—42 mcg/puff; triamcinolone—
                  (168–1,008 mcg)                                100 mcg/puff; flunisolide—250 mcg/puff.

                                                                 The number of puffs per dose presented here is
                                                                 taken from the NAEPP Guidelines. These doses
                                                                 were considered to be illustrative and they
                                                                 referred to beclomethasone. In the absence of
                                                                 complete data, the same dosage in micrograms
                                                                 may be applied to other inhaled steroid formula-
                                                                 tions—triamcinolone and flunisolide. However,
                                                                 you may see prescribed dosages in micrograms
                                                                 that vary across different inhaled steroid
                                                                 preparations. This may be due to the fact that
                                                                 the studies that established the efficacy and
                                                                 safety of these preparations, to date, have used
                                                                 different microgram dosages.

                                                                 Corticosteroids are not the same as anabolic
                                                                 steroids, which are used illicitly by some athletes.
                                                                 Corticosteroids are relatively safe when used as
                                                                 prescribed.

                                                                 Tips
                                                                 Use a spacer device and rinse the mouth after
                                                                 taking the medicine.

                                                                 Treat yeast infections with antifungal therapy.




                                                                                                                   37
Appendix A




Medication        Dosage                      Side Effects                 Comments/Tips

Oral              Children                    Short term: increased        Comments
corticosteroids   Severe Asthma               appetite, fluid retention,   Use in short bursts to help patients control and
                  Less than 5 years old       weight gain, swelling of     recover from severe asthma episodes. May only
                  5-10 mg alternate days      face, changes in mood,       be needed for a few days.
                  decrease to lowest          high blood pressure,
                  dose that stabilizes        peptic ulcer, aseptic        Use for a prolonged period of time only if a
                  symptoms and peak           necrosis of the hip,         patient’s asthma is very severe. Monitor long-
                  flow                        abnormalities of glucose     term side effects.
                                              metabolism
                  Over 5 years old                                         During prolonged use, side effects may be
                  Use the lowest alternate    Long term: thinning of       minimized by a single a.m. dose given on
                  a.m. dose that stabilizes   the bones (osteoporosis),    alternate days.
                  symptoms and peak           high blood pressure,
                  flow                        Cushing’s syndrome,          Goal is to switch to inhaled corticosteroids
                                              cataracts, muscle            ultimately.
                  Adults                      weakness, fragile skin,
                  Severe Asthma               petechiae, peptic ulcer,     Tips
                  Burst for active            aseptic necrosis of the      Take with food to avoid stomach irritation.
                  symptoms (40 mg a           hip, abnormalities of
                  day, single or divided      glucose metabolism,          For long courses of therapy, side effects may
                  dose, for 1 week,           impairment of the            be minimized by a single a.m. dose given on
                  then tapered for            immune system,               alternate days.
                  1 week)                     potassium loss,
                                              hypothalamic-pituitary       Have long-term use assessed frequently
                                              suppression, slower          with an optimal goal of switching to inhaled
                                              growth in children,          corticosteroids.
                                              changes in mood
                                                                           Monitor children’s growth patterns.

                                                                           Have ophthalmology exams every 1 to 2 years
                                                                           with long-term use.




38
                                                        Dosages and Side Effects of Medications for Chronic Asthma




Bronchodilator medications open up the airways.

Medication       Dosage                      Side Effects             Comments/Tips

Short-acting     Children                    Nervousness, tremor,     Use episodically to treat and control asthma
inhaled beta2-   Metered-dose inhaler        anxiety, nausea, rapid   symptoms and episodes.
agonists         (e.g., albuterol,           heart rate, headache,
                 metaproterenol,             dizziness, vomiting      Works within 5 to 15 minutes and lasts 4 to 6
                 bitolterol, terbutaline,                             hours.
                 pirbuterol)
                   2 puffs every 4–6 hours                            Can be taken before exercise or contact with
                   PRN                                                asthma trigger to prevent symptoms.

                 Dry powder inhaler                                   A holding chamber or spacer device attached to
                   1 capsule every 4–6                                an inhaler makes the inhaler easier to use by ALL
                   hours PRN                                          patients.

                 Nebulizer solution                                   In particular, use a nebulizer with children under
                 Albuterol                                            age 5, patients who have trouble using an
                   5 mg/mL; 0.1–0.15                                  inhaler, and patients with severe asthma
                   mg/kg in 2 cc of saline                            episodes.
                   every 4–6 hours
                   (maximum 5.0 mg)                                   Nebulizer solution of bitolterol is not
                                                                      recommended for children under 12 years of
                 Metaproterenol                                       age.
                  50 mg/mL;
                  0.25–0.50 mg/kg in
                  2 cc of saline every
                  4–6 hours
                  (maximum 15.0 mg)

                 Adults
                 Metered-dose inhaler
                 (e.g., albuterol,
                 metaproterenol,
                 bitolterol, terbutaline,
                 pirbuterol)
                   2 puffs every 4–6 hours
                   PRN

                 Dry powder inhaler
                   1 capsule every
                   4–6 hours PRN

                 Nebulizer solution
                 Albuterol, bitolterol,
                 metaproterenol
                   (see package insert)




                                                                                                                      39
Appendix A




Medication       Dosage                   Side Effects             Comments/Tips

Long-acting      Salmeterol               Nervousness, tremor,     A relatively new medication that the NAEPP has
inhaled beta2-     (NAEPP has             anxiety, nausea, rapid   not reviewed to clearly define its role in asthma
agonists           no dosage              heart rate, headache,    therapy.
                   recommendation         dizziness, vomiting
                   at this time.)                                  Added to the regimen when inhaled
                                                                   corticosteroids are not sufficient to control
                                                                   symptoms. Used to help prevent asthma
                                                                   symptoms and episodes.

                                                                   Generally, should not be used more than twice
                                                                   a day.

                                                                   Not for the immediate relief of symptoms during
                                                                   an asthma episode. During an episode, patients
                                                                   should use a short-acting beta2-agonist but also
                                                                   continue their regular schedule of salmeterol.

                                                                   Recommended for adults and children 12 years
                                                                   of age and older.

Oral beta2-      Children                 Nervousness, tremor,     Comments
agonists         Liquid albuterol         anxiety, nausea, rapid   Begins to work within 30 minutes and lasts as
                   0.1–0.15 mg/kg every   heart rate, headache,    long as 4 to 6 hours. Inhaled beta2-agonists are
                   4–6 hours              dizziness, vomiting      faster acting and preferred for treating acute
                 Liquid metaproterenol                             episodes.
                   0.3–0.5 mg/kg every
                   4–6 hours                                       Long-acting oral beta2-agonists are helpful for
                 Tablet albuterol                                  nocturnal asthma symptoms.
                   2 or 4 mg tablet
                   every 4–6 hours;                                Tips
                   4 mg extended-                                  Inhaled beta2-agonists have fewer side effects
                   release tablet every                            than liquids or tablets.
                   12 hours
                 Tablet metaproterenol
                   10 or 20 mg tablet
                   every 4–6 hours
                 Tablet terbutaline
                   2.5 or 5.0 mg tablet
                   every 4–6 hours

                 Adults
                 Albuterol
                   4 or 8 mg extended-
                   release tablet every
                   12 hours




40
                                                            Dosages and Side Effects of Medications for Chronic Asthma




Medication         Dosage                       Side Effects                  Comments/Tips

Theophylline       Liquid, tablets, capsules,   Nausea, vomiting,             Comments
                   and extended-release         stomach cramps,               Sustained-release theophylline is helpful for
                   dosage to achieve            diarrhea, headache,           nocturnal asthma symptoms.
                   serum concentration          muscle cramps, rapid or
                   of 5–15 µg/mL                irregular heart beat,         Preferred time for once daily dosage is 6–7 p.m.
                                                irritability, restlessness,
                   Pregnant Women               increased urination,          Doses should not be increased or other brands
                   Dosage to achieve            seizure, coma                 substituted without consulting the doctor.
                   serum concentration
                   of 8–12 µg/mL                                              Theophylline blood levels are monitored to make
                                                                              sure concentrations are not too high. A simple
                                                                              blood test may be performed 3 to 4 days after
                                                                              starting and at 6- to 12-month intervals.

                                                                              Tips
                                                                              Advise physician of changes in concomitant
                                                                              medicines. Theophylline levels are affected
                                                                              by antibiotics (e.g., erythromycin), phenytoin,
                                                                              cimetidine, and other medications. Having
                                                                              a fever, influenza, impaired liver or kidney
                                                                              function, and other conditions can also affect
                                                                              theophylline serum levels.

                                                                              Take with food to avoid stomach irritation.

                                                                              Refrain from chewing tablets or mixing
                                                                              theophylline with hot food to avoid releasing
                                                                              too much medicine into the body at one time.

Anticholinergics                                                              Benefits of use in the day-to-day management of
                                                                              of asthma have not been established.

                                                                              Some report of incremental benefits when used
                                                                              in nebulized form with nebulized beta2-agonists
                                                                              to treat severe asthma episodes.




                                                                                                                                41
    APPENDIX B

    DOSAGES          FOR     ACUTE EXACERBATIONS                        OF   ASTHMA



    Medications               Dosage

    Inhaled beta2-agonists    Children
                              Metered-dose inhaler
                              Albuterol                 2 puffs every 5 minutes for a total of 12 puffs
                                                        (Use PEFR or FEV1 to document response.)
                                                        If not improved, switch to nebulizer.
                                                        If improved, decrease to 4 puffs every hour.

                              Metaproterenol            2 inhalations

                              Terbutaline               2 puffs every 5 minutes for a total of 12 puffs

                              Nebulizer solution
                              Albuterol                 0.1–0.15 mg/kg/dose up to 5 mg every 20 minutes for
                                                        1–2 hours (minimum dose 1.25 mg/dose)
                                                        If improved, decrease to 1–2 hours.
                                                        If not improved, use by continuous inhalation.

                              Metaproterenol            0.1–0.3 cc (5–15 mg)
                                                        Do not exceed 15 mg.

                              Adults
                              Nebulizer solution
                              (dilute solutions with 2–3 cc normal saline)
                              Albuterol                  2.5 mg (0.5 cc of a 0.5% solution)

                              Metaproterenol            15 mg (0.3 cc of a 5% solution)

                              Isoetharine               5 mg (0.5 cc of a 1% solution)

    Systemic beta-agonists    Children
                              Epinephrine HCl           0.01 mg/kg up to 0.3 mg s.q. every 20 minutes for 3 doses

                              Terbutaline               0.01 mg/kg up to 0.3 mg s.q. every 2–6 hours as needed

B                                                       10 µg/kg IV over 10 minutes loading dose
                                                        Maintenance: 0.4 µg/kg/min. Increase as necessary by
                                                        0.2 µg/kg/min and expect to use 3–6 µg/kg/min.

                              Adults
                              Epinephrine               0.3 mg subcutaneous

                              Terbutaline               0.25 mg subcutaneous




    42
                                                            Dosages for Acute Exacerbations of Asthma




Medications       Dosage


Corticosteroids   Children
                  Outpatients
                  Oral prednisone,           1–2 mg/kg/day in single or divided doses
                  prednisolone, or
                  methylprednisolone

                  Emergency Department or Hospitalized Patients (IV or P.O.)
                  Methylprednisolone    1–2 mg/kg/dose every 6 hours for 24 hours,
                  (IV or P.O.)          then 1–2 mg/kg/day in divided doses every 8–12 hours

                  Adults
                  Intravenous
                  Methylprednisolone         60–80 mg IV bolus every 6–8 hours

                  Hydrocortisone             2.0 mg/kg IV bolus every 4 hours, or 2.0 mg/kg IV bolus,
                                             then 0.5 mg/kg/hr continuous IV infusion

                  Oral
                  s Prednisone or methylprednisolone 60 mg given immediately; then 60–120 mg/day
                    in divided doses and tapered over several days may be given instead of an IV
                    regimen.

                  s   With improvement, corticosteroids usually are tapered to a single daily dose (e.g.,
                      60 mg/day) or divided doses (e.g., 20 mg tid), then reduced over several days.

                  s   For long courses of therapy, side effects may be minimized by a single a.m. dose
                      given on alternate days.




                                                                                                        43
    APPENDIX C
    ASSESSING           AND      MEETING NEEDS:
    EXAMPLES            OF    PATIENT EDUCATION                FOR     EACH CLINIC VISIT


    The way you organize and conduct your visits                  – Ask if the patient has concerns that he or
    with patients will have a dramatic effect on their              she wants to have addressed at this visit.
    following your directions, their satisfaction with
                                                                  – Tell the patients when their concerns will be
    their care, and their management of their asthma.
                                                                    addressed during the visit. Ask if the plans
    Specific examples of patient education for the first
                                                                    for this visit are likely to meet the patient’s
    and subsequent visits are described in detail in
                                                                    needs.
    this appendix. The following three-part patient
    education process is used to organize every visit.         b. Determine if patients are at high risk for
    These “parts” can recur more than once within a               an asthma-related death or life-threatening
    single session (e.g., assess progress and agree on            episode. Patients at high risk should receive
    next steps for two or more actions).                          greater attention and vigilance. The following
                                                                  are risk factors for asthma-related death:
     I. Assess needs, expectations, and progress.
                                                                  – Age: 17–24, >55 years old.
    II. Introduce/review an action patient needs
        to take.                                                  – African American, especially those 15 to 44
                                                                    years of age.
         – Review the benefits of doing the action.
                                                                  – Previous life-threatening acute asthma
         – Identify concerns and barriers, and problem              episode.
           solve.
                                                                  – Hospital admission for asthma in the past
         – Teach the action—describe action, show action,           year.
           have patient do the action, give feedback.
                                                                  – Inadequate general medical management.
         – Devise ways to help the patient remember when
           to take the action.                                    – Psychological and psychosocial problems
                                                                    (e.g., depression, alcohol abuse, recent
    III. Obtain an agreement with the patient to take               family death and disruption, recent unem-
         specific action(s), and say you will discuss his or        ployment, schizophrenia, extreme anxiety).
         her progress at the next visit.
                                                               c. Assess resources and family support with
    FIRST VISIT: PATIENT ASSESSMENT AND                           simple questions requiring only “yes” and “no”
C                EXPECTATIONS
    I.a. Introduce yourself and agree on expecta-
                                                                  answers (discuss periodically after the first
                                                                  visit).
         tions for the visit.                                     – Insurance. “Are your doctor’s visits and
                                                                    medications covered by private insurance,
         – Explain what will happen during the visit.
                                                                    Medicare, or Medicaid?” “Do you think
                                                                    you may need financial assistance?”



    44
                              Assessing and Meeting Needs: Examples of Patient Education for Each Clinic Visit




   – Family opinions. “Does your family                       – Ask patient to agree to take specific actions
     understand your problems with asthma?”                     (e.g., taking medicine) discussed in this visit.
     “Are they helpful and supportive of your
     getting proper treatment?” Discuss                  ROUTINE VISITS: ASSESSMENT, INSTRUCTION,
     responses if there is time.                                         REVIEW, AND AGREEMENT
   – Companion at visits. “Would you like                I.a. Agree on expectations for the visit.
     to bring a family member to your next                    – Explain what will happen during the visit.
     appointment so he or she can learn about
     your asthma and its treatment?”                          – Ask if the patient has concerns that he or
                                                                she wants to have addressed at this visit.
d. Ask about consequences of asthma.
                                                              – Tell the patients when their concerns will be
   – “How does asthma affect your life?”                        addressed during the visit. Ask if the plans
     Identify the consequences of asthma that                   for this visit are likely to meet the patient’s
     they would like to prevent. Discuss how                    needs.
     likely it is that problems will continue if
     they do not take the appropriate action.             b. Assess achievement of the goals of asthma
                                                             management. (Simple questions requiring
e. Ask about expected benefits of treatment.                 only “yes” and “no” answers can be quickly
   – “What do you expect the treatment will                  asked).
     help you to do?” Review the goals of                     – Symptoms. “Do you have any of the
     asthma management and tell the patient                     following symptoms during the day or night
     that these can be achieved by the patient                  since your last visit or in the last month—
     and health care team working together.                     coughing, wheezing, chest tightness,
     Present the benefits that would be lost by                 shortness of breath?”
     not taking the steps needed to control
     asthma (e.g., lose control of asthma).                     s   If yes, ask when, where, how often, and
                                                                    during what activity they occurred.
 f. Identify patient concerns/issues.
                                                              – Exercise. “Do you have symptoms during
   – “What concerns do you have about your                      or after exercising or after exertion?” “Do
     asthma and its treatment?”                                 activities such as running, climbing stairs,
                                                                cleaning house, or laughing cause any
II. Teach patients how and when to use their
                                                                symptoms in you?” “How many times a
    metered-dose inhaler(s). (See table 4, page
                                                                week do you usually exercise?”
    15 and patient handout in appendix D.)
                                                              – Routine interrupted. “Has your asthma
III. Explain and agree on the demands of                        kept you from going to school, working, or
     treatment.                                                 doing other routine activities?”
   – Explain generally what the course of treat-              – Emergency/additional care. “Have you
     ment will be, that treatment will be                       gone to an emergency department, hospital,
     ongoing and long term, and how often                       or walk-in clinic for your asthma since the
     they will need to come to the office. Tell                 last visit?”
     them you will be helping them to achieve
     and maintain control of their asthma.                    – Side effects. “What side effects have you
     Ask if this is acceptable to them.                         had from your medicines?” “Do you feel
                                                                shaky or nervous?” “Are you having a bad



                                                                                                             45
Appendix C




       taste, cough, or upset stomach?” “Are you          • Demonstration by patient of his or her
       having trouble working?” “Do you have                inhaler/spacer and/or nebulizer tech-
       any other problems with medicines?”                  nique.
 c. Assess activities in the components of           d. Review an activity patients agreed to do at
    asthma management.                                  last visit (followup visits only).
     – Objective measures—peak flow moni-               – Review activities/praise. “What were you
       toring                                             able to do regarding _______ [specific
                                                          action]? Praise some aspect of the patient’s
       • Ask what time the patient checks his or
                                                          effort.
         her peak flow rate each day.
                                                        – Define problems/barriers. “Did you have
       • Review the pattern of the patient’s daily
                                                          trouble with any actions that we discussed
         peak flow rate.
                                                          at the last visit?” “What seemed to be the
       • Have patient demonstrate peak flow               problem?”
         meter technique.
                                                          s   Unclear what action was
     – Environmental control
                                                          s   Benefits not achieved/believed
       • Problems. “What seems to make your
                                                          s   Lacked skills/confidence
         asthma worse?”
                                                          s   Forgot
       • Actions. “What have you done (or will
         you do) to stay away from things that            s   Barriers present—time, circumstances,
         make your asthma worse?”                             other people, finances, etc.
     – Pharmacotherapy                                  – Problem solve with patient. Discuss how
                                                          to resolve the problem with the patient.
       • Medications taken now. “How much
                                                          For example, if patients forget, help them
         and how often do you take _______
                                                          find ways to remind themselves. If they
         medication?” If inhaled, “What is the
                                                          lack skills and confidence, reteach using the
         name and color of the inhaler?”
                                                          four R’s. If they seem confused or over-
       • Treatment of symptoms. “What do                  whelmed, reduce the number of manage-
         you do when you begin noticing symp-             ment activities patients are to do or the
         toms?” “What medication do you take?”            complexity of the activities.
         Review asthma management plan.
                                                        – Be positive. Suggest that patients learn
       • What other medications do you take for           from and then forget about any mistakes
         your asthma?                                     they may have made. Encourage them to
                                                          keep trying. They will succeed with time.
       • Access to medicines. “Do you have any
         problems getting your medicine at any          – Reinforce benefits. “How helpful was
         time (e.g., at school or work)?”                 ________ [a specific asthma management
                                                          activity]?” For example, “What effects do
       • Effectiveness of medications. “Do the
                                                          you think the inhaled steroids had?”
         medicines seem to be working for you?”
                                                          Remind patients that it can take a few
         (Clarify/reinforce benefits.)
                                                          weeks before they notice benefits from
       • Concerns or questions. “Do you have              inhaled steroids. Reinforce benefits men-
         any concerns or questions about your             tioned and address any problems.
         medicine?”


46
                               Assessing and Meeting Needs: Examples of Patient Education for Each Clinic Visit




    – Agree upon patient’s plans to act. Ask                     flow rate every morning when I brush my
      the patient to agree to take the specific                  teeth and record the rate on my peak flow
      action and say you will discuss his or her                 diary at that time)?” Or simply ask, “How
      experience with him or her at the next visit.              likely are you to do _______ [specific
                                                                 action], _______[frequency], over the next
II. Introduce a new activity using the process                   month?”
    below (as needed).
                                                              – Devise reminders. Discuss how patients
    – Propose an action. Tell the patient what                  can remind themselves to take the agreed-
      action he or she needs to learn next (e.g.,               upon actions.
      peak flow rate monitoring). “I would like
      to talk to you about this action today. Is          CLOSING FOR ALL VISITS
      that OK?”                                           Assess satisfaction. “Were your concerns and
    – Present benefits. Present the key benefits          questions during this visit addressed satisfactorily?”
      to the patient. Ask, “How do you think              Other satisfaction questions include: “How did
      this could be helpful to you given your             your visit with Dr.____ go?” “Is there anything
      experience with asthma?”                            that was said that you weren’t sure you under-
                                                          stood?” “How could we make your visit more
    – Teach. Use the four R’s to guide teaching           helpful to you in the future?” Provide feedback to
      (reach agreement, rehearse, repeat, rein-           the rest of the health professionals and make
      force).                                             appropriate notations in the patient record.
    – Address barriers. “What do you think                Review/confirm agreements. Obtain or confirm
      might keep you from doing this asthma               the patient’s commitment and plans to take each
      management activity?” “What might make              recommended action.
      it difficult?” “How can these problems/
      difficulties be reduced?”                           Express interest in future progress. ALWAYS
                                                          tell patients you will talk to them about their
    – Make specific plans. “During the next
                                                          agreed-upon actions at their next visit. Convey
      month, what do you plan to do regarding
                                                          interest in their progress and do not make this
      _______ [specific action] (e.g., taking peak
                                                          sound like you are checking up on them.




                                                                                                             47
    APPENDIX D

    PATIENT HANDOUTS*



    How To Use Your Peak Flow Meter
    My Asthma Symptoms and Peak Flow Diary
    Asthma Management Plan
    How To Stay Away From Things That Make Your Asthma Worse
    Your Metered-Dose Inhaler: How To Use It
    Spacers: Making Inhaled Medicines Easier To Take
    How To Use and Care for Your Nebulizer




    *Please duplicate for patient use as needed.




D
    48
                         HOW TO USE YOUR PEAK FLOW METER

A peak flow meter is a device that measures how well air moves out of your lungs. During an asthma
episode the airways of the lungs begin to narrow slowly. The peak flow meter will tell you if there is
narrowing in the airways days—even hours—before you have any symptoms of asthma.
By taking your medicine(s) early (before symptoms), you may be able to stop the episode quickly and
avoid a severe episode of asthma. Peak flow meters are used to check your asthma the way that blood
pressure cuffs are used to check high blood pressure.
The peak flow meter can also be used to help you and your doctor:
    s   Learn what makes your asthma worse.
    s   Decide if your medicine plan is working well.
    s   Decide when to add or stop medicine.
    s   Decide when to seek emergency care.
A peak flow meter is most helpful for patients who must take asthma medicine daily. Patients age 5
and older are able to use a peak flow meter. Ask your doctor or nurse to show you how to use a peak
flow meter.


HOW TO USE YOUR PEAK FLOW METER                         FIND YOUR PERSONAL BEST PEAK
s Do the following five steps with your peak flow       FLOW NUMBER
  meter:                                                Your personal best peak flow number is the
    1. Put the indicator at the bottom of the num-      highest peak flow number you can achieve over
                                                        a 2-week period when your asthma is under good
       bered scale.
                                                        control. Good control is when you feel good and
    2. Stand up.                                        do not have any asthma symptoms.
    3. Take a deep breath.                              Each patient’s asthma is different, and your best
    4. Place the meter in your mouth and close your     peak flow may be higher or lower than the peak
       lips around the mouthpiece. Do not put your
       tongue inside the hole.
    5. Blow out as hard and fast as you can.
s   Write down the number you get.
s   Repeat steps 1 through 5 two more times and
    write down the numbers you get.
s   Write down in “My Asthma Symptoms and
    Peak Flow Diary” the highest of the three
    numbers achieved.
                                                        There are a variety of peak flow meters.


                                                                                                   49
flow of someone of your same height, weight, and                            peak flow number does not return to the Yellow
sex. This means that it is important for you to                             or Green Zone and stay in that zone.
find your own personal best peak flow number.
                                                                            Record your personal best peak flow number
Your medicine plan needs to be based on your
own personal best peak flow number.                                         and peak flow zones at the top of “My Asthma
                                                                            Symptoms and Peak Flow Diary.”
To find out your personal best peak flow number,
take peak flow readings:                                                    USE THE DIARY TO KEEP TRACK OF
s   Every day for 2 weeks.                                                  YOUR PEAK FLOW
                                                                            Write down your peak flow number on the diary
s   Mornings and early afternoons or evenings                               every day, or as instructed by your doctor.
    (when you wake up and between 12:00 and
    2:00 p.m.).                                                             ACTIONS TO TAKE WHEN PEAK FLOW
s   Before and after taking inhaled beta2-agonist                           NUMBERS CHANGE
    (if you take this medicine).
s   As instructed by your doctor.                                           s   PEFR goes more than 20 percent below
                                                                                your personal best (PEFR is in the Yellow
Write down these readings in your peak flow                                     Zone).
diary.
                                                                                ACTION: Take an inhaled short-acting
THE PEAK FLOW ZONE SYSTEM                                                               bronchodilator as prescribed by
Once you know your personal best peak flow                                              your doctor.
number, your doctor will give you the numbers
that tell you what to do. The peak flow numbers                             s   PEFR changes 20 percent or more between
are put into zones that are set up like a traffic                               the morning and early afternoon or evening
light. This will help you know what to do when                                  (measure your PEFR before taking medicine).
your peak flow number changes. For example:
                                                                                                   or
    Green Zone (80 to 100 percent of your
    personal best number) signals good control.                             s   PEFR increases 20 percent or more when
    No asthma symptoms are present. You may                                     measured before and after taking an in-
take your medicines as usual.                                                   haled short-acting bronchodilator.
    Yellow Zone (50 to 79 percent of your                                       ACTION: Talk to your doctor about adding
    personal best number) signals caution. You                                          more medicine to control your
    may be having an episode of asthma that                                             asthma better (for example, an
requires an increase in your medicines. Or your                                         anti-inflammatory medication).
overall asthma may not be under control, and the
doctor may need to change your medicine plan.
    Red Zone (below 50 percent of your personal
    best number) signals danger! You must take
    a short-acting inhaled beta2-agonist right
away and call your doctor immediately if your
Nurses: Partners in Asthma Care, National Asthma Education and Prevention Program,
National Heart, Lung, and Blood Institute, NIH Publication No. 95-3308, 1995.
            50
                          MY ASTHMA SYMPTOMS AND PEAK FLOW DIARY
     ________ My predicted peak flow                                                      ________ My personal best peak flow

     ____ My Green (Good Control) Zone ______ My Yellow (Caution) Zone ______ My Red (Danger) Zone
              80–100% of personal best                          50–79% of personal best             below 50% of personal best


                  Date:
                            a.m. p.m.        a.m. p.m.        a.m. p.m.       a.m. p.m.     a.m. p.m.   a.m. p.m.    a.m. p.m.
            Peak Flow
              Reading
          No Asthma
           Symptoms
        Mild Asthma
          Symptoms
 Moderate Asthma
       Symptoms
     Serious Asthma
          Symptoms
     Medicine Used
 to Stop Symptoms
         Urgent Visit
       to the Doctor

Directions:
1. Take your peak flow reading every morning (a.m.) when you wake up and every afternoon or evening
   (p.m.). Try to take your peak flow readings at the same time each day. If you take an inhaled beta2-agonist
   medicine, take your peak flow reading before taking that medicine. Write down the highest reading of
   three tries in the box that says peak flow reading.
2. Look at the box at the top of this sheet to see whether your number is in the Green, Yellow, or
   Red Zone.
3. In the space below the date and time, put an “X” in the box that matches the symptoms you have when
   you record your peak flow reading; see description of symptom categories below.
4. Look at your Asthma Management Plan for what to do when your number is in one of the zones or
   when you have asthma symptoms.
5. Put an “X” in the box beside “medicine used to stop symptoms” if you took extra asthma medicine to
   stop your symptoms.
6. If you made any visit to your doctor’s office, emergency department, or hospital for treatment of an asthma
   episode, put an “X” in the box marked “urgent visit to the doctor.” Tell your doctor if you went to the
   emergency department or hospital.
No symptoms            = No symptoms (wheeze, cough, chest tightness, or shortness of breath) even with
                          normal physical activity.
Mild symptoms          = Symptoms during physical activity, but not at rest. It does not keep you from
                          sleeping or being active.
Moderate symptoms = Symptoms while at rest; symptoms may keep you from sleeping or being active.
Severe symptoms        = Severe symptoms at rest (wheeze may be absent); symptoms cause problems walking
                          or talking; muscles in neck or between ribs are pulled in when breathing.
Nurses: Partners in Asthma Care, National Asthma Education and Prevention Program,
National Heart, Lung, and Blood Institute, NIH Publication No. 95-3308, 1995.

                                                                                                                    51
Date: ________________________                                 Personal Best PEFR   ___________________________



ASTHMA MANAGEMENT PLAN FOR _______________________________

                                     Green Zone = Good control
Green Zone: _______ to _______ Peak Flow Rate (80–100% of personal best; no symptoms)
To keep your asthma under control: Stay away from things that make your asthma worse
(such as animals, smoke, etc.; talk to your doctor about these things). Take your medicine(s).

        Name of                                 How Much                             How Often/
        Medicine                                 To Take                            When To Take It
 __________________________________________________________________________________________________________

 __________________________________________________________________________________________________________

 __________________________________________________________________________________________________________

 __________________________________________________________________________________________________________




                                        Yellow Zone = Caution
Yellow Zone: _______ to _______ Peak Flow Rate (50–79% of personal best)
Take medicine listed below to get your asthma back under control.
Symptoms: Coughing, wheezing, shortness of breath, tightness in the chest, or other symptoms
of an asthma episode. Symptoms may be mild.
Early signs your asthma is getting worse: _________________________________________________
Take your Yellow Zone medicine when these early signs occur.

        Name of                                 How Much                             How Often/
        Medicine                                 To Take                            When To Take It
 __________________________________________________________________________________________________________

 __________________________________________________________________________________________________________

 __________________________________________________________________________________________________________

 __________________________________________________________________________________________________________

s   Peak flow rate or symptoms not better in ______ minutes after taking the medicine listed
    above? Call the doctor.
s   Keep taking your Green Zone medicine(s). Keep staying away from things that make your
    asthma worse.




                                                                                                   53
                                                        Red Zone = Danger!
   Red Zone: Below _______ Peak Flow Rate (below 50% of personal best)
   Take the medicine listed below. Then call your doctor.
   Symptoms: Coughing, very short of breath, trouble walking and talking, tightness in the chest,
   other symptoms.
            Name of                                             How Much              How Often/
            Medicine                                             To Take             When To Take It
    __________________________________________________________________________________________________________

    __________________________________________________________________________________________________________

    __________________________________________________________________________________________________________

    __________________________________________________________________________________________________________

   s   Call your doctor or emergency room NOW, say this is an emergency, and ask what you
       should do next.
   s   Go to the doctor or hospital right away or call an ambulance without delay if:
       – You are struggling to breathe or your lips or fingernails turn a little blue or grey.
       – Your peak flow remains in the Red Zone level 20 minutes after taking your medicine.
   s   Keep taking your Green Zone medicine(s).


Doctor: ________________________________________________________________________________

Office Phone: ___________________________________________________________________________

Phone Number After Office Hours: _______________________________________________________

Emergency Room: ______________________________________________________________________


  Notes
    __________________________________________________________________________________________________________

    __________________________________________________________________________________________________________

    __________________________________________________________________________________________________________

    __________________________________________________________________________________________________________

    __________________________________________________________________________________________________________

    __________________________________________________________________________________________________________

    __________________________________________________________________________________________________________


Nurses: Partners in Asthma Care, National Asthma Education and Prevention Program,
National Heart, Lung, and Blood Institute, NIH Publication No. 95-3308, 1995.


            54
                                HOW TO STAY AWAY FROM THINGS
                                THAT MAKE YOUR ASTHMA WORSE
Because you have asthma, your airways are very sensitive. They may react to things that can cause asthma
attacks or episodes. Staying away from such things will help you keep your asthma from getting worse.
    s   Ask your doctor to help you find out what makes your asthma worse. Discuss the ways to stay
        away from these things. The tips listed below will help you.
    s   Ask your doctor for help in deciding which actions will help the most to reduce your asthma
        symptoms. Carry out these actions first. Discuss the results of your efforts with your doctor.


           Tips for Those Allergic to or Bothered by Any Item Listed Below

House-Dust Mites                                                vacuum cleaner bags and exhaust-port HEPA
                                                                (high-efficiency particulate air) filters.
The following actions should help you control
house-dust mites:
s   Encase your mattress and box spring in an
                                                                         Animals
    airtight cover.
s   Either encase your pillow or wash it in hot             Some people are allergic to the dried flakes of
    water once a week every week.                           skin, saliva, or urine from warm-blooded pets.
                                                            Warm-blooded pets include ALL dogs, cats, birds,
s   Wash your bed covers, clothes, and stuffed toys         and rodents. The length of a pet’s hair does not
    once a week in hot water (130 °F).                      matter. Here are some tips for those allergic to
                                                            animals:
The following actions will also help you
control dust mites—but they are not essential:              s   Remove the animal from the home or school
                                                                classroom.
s   Reduce indoor humidity to less than 50 per-
    cent. Use a dehumidifier if needed.                     s   Choose a pet without fur or feathers (such as
                                                                a fish or a snake).
s   Remove carpets from your bedroom.
                                                            s   If you must have a warm-blooded pet, keep the
s   Do not sleep or lie on upholstered furniture.               pet out of your bedroom at all times. Keeping
    Replace with vinyl, leather, or wood furniture.             the pet outside of your home is even better.
s   Remove carpets that are laid on concrete.               s   If there is forced-air heating in the home with
s   Stay out of a room while it is being vacuumed.              a pet, close the air ducts in your bedroom.
s   If you must vacuum, one or more of the follow-          s   Wash the pet weekly in warm water.
    ing things can be done to reduce the amount of          s   Do not visit homes that have pets. If you
    dust you breathe in: (1) Use a dust mask. (2)               must visit such places, take asthma medicine
    Use a central vacuum cleaner with the collect-              (cromolyn is often preferred) before going.
    ing bag outside the home. (3) Use double-wall

                                                                                                     55
s   Do not buy or use products made with feathers.
    Use pillows and comforters stuffed with syn-
    thetic fibers like polyester. Also do not use                  Strong Odors and Sprays
    pillows, bedding, and furniture stuffed with
    kapok (silky fibers from the seed pods of the     s   Do not stay in your home when it is being
    silk-cotton tree).                                    painted. Use latex rather than oil-based paint.
s   Use a vacuum cleaner fitted with a HEPA filter.   s   Try to stay away from perfume, talcum powder,
                                                          hair spray, and products like these.
s   Wash hands and change clothes as soon as you
    can after being in contact with pets.             s   Use household cleaning products that do not
                                                          have strong smells or scents.
                                                      s   Reduce strong cooking odors (especially frying)
             Cockroaches (Some people are
                                                          by using an exhaust fan and opening windows.
             allergic to the droppings of roaches.)
s   Use insect sprays; but have someone else spray    Colds and Infections
    when you are outside of the home. Air out the
    home for a few hours after spraying. Roach        s   Talk to your doctor about flu shots.
    traps may also help.                              s   Stay away from people with colds or the flu.
s   All homes in multiple-family dwellings (apart-    s   Do not take over-the-counter cold remedies,
    ments, condominiums, and housing projects)
                                                          such as antihistamines and cough syrup, unless
    must be treated to get rid of roaches.
                                                          you speak to your doctor first.


             Tobacco Smoke
s   Do not smoke.                                                  Exercise
s   Do not allow smoking in your home. Have           s   Make a plan with your doctor that allows you
    household members smoke outside.                      to exercise without symptoms. For example,
s   Encourage family members to quit smoking.             take inhaled beta2-agonist or cromolyn less
    Ask your doctor or nurse for help on how to           than 30 minutes before exercising.
    quit.                                             s   Do not exercise during the afternoon when air
s   Choose no-smoking areas in restaurants, hotels,       pollution levels are highest.
    and other public buildings.                       s   Warm up before doing exercise and cool down
                                                          afterward.
Wood Smoke
s   Do not use a wood-burning stove to heat your
    home.
s   Do not use kerosene heaters.


           56
Weather                                                                     s   Pets should either stay outdoors or indoors.
                                                                                Pets should not be allowed to go in and out
s   Wear a scarf over your mouth and nose in cold                               of the home. This prevents your pet from
    weather. Or pull a turtleneck or scarf over                                 bringing pollen inside.
    your nose on windy or cold days.                                        s   Do not mow the grass. But if you must mow,
s   Dress warmly in the winter or on windy days.                                wear a pollen filter mask.

                                                                            Mold (Outdoor)

                Pollens
                                                                            s   Avoid sources of molds (wet leaves, garden
                                                                                debris, stacked wood).
During times of high pollen counts:                                         s   Avoid standing water or areas of poor drainage.
s   Stay indoors during the midday and                                      REMEMBER: Making these changes will help
    afternoon when pollen counts are highest.                               keep asthma episodes from starting. These
s   Keep windows closed in cars and homes. Use                              actions can also reduce your need for asthma
    air conditioning if you can.                                            medicines.


    Notes
    __________________________________________________________________________________________________________

    __________________________________________________________________________________________________________

    __________________________________________________________________________________________________________

    __________________________________________________________________________________________________________

    __________________________________________________________________________________________________________

    __________________________________________________________________________________________________________

    __________________________________________________________________________________________________________

    __________________________________________________________________________________________________________

    __________________________________________________________________________________________________________

    __________________________________________________________________________________________________________

    __________________________________________________________________________________________________________

    __________________________________________________________________________________________________________

    __________________________________________________________________________________________________________

    __________________________________________________________________________________________________________

    __________________________________________________________________________________________________________


Nurses: Partners in Asthma Care, National Asthma Education and Prevention Program,
National Heart, Lung, and Blood Institute, NIH Publication No. 95-3308, 1995.


                                                                                                                    57
                    YOUR METERED-DOSE INHALER: HOW TO USE IT

Using a metered-dose inhaler is a good way to take asthma medicines. There are few side effects because
the medicine goes right to the lungs and not to other parts of the body. It takes only 5 to 10 minutes for
inhaled beta2-agonists to have an effect compared to the liquid or pill form, which can take 15 minutes to
1 hour. Inhalers can be used by all asthma patients age 5 and older. A spacer or holding chamber at-
tached to the inhaler can help make taking the medicine easier.
The inhaler must be cleaned often to prevent buildup that will clog it or reduce how well it works.
  s   The guidelines that follow will help you use the inhaler the correct way.
  s   Ask your doctor or nurse to show you how to use the inhaler.


USING THE INHALER                                            C. Put inhaler in mouth and seal lips around
1. Remove the cap and hold the inhaler upright.                 the mouthpiece.
2. Shake the inhaler.                                     5. Press down on the inhaler to release the medi-
                                                             cine as you start to breathe in slowly.
3. Tilt your head back slightly and breathe out.
                                                          6. Breathe in slowly for 3 to 5 seconds.
4. Use the inhaler in any one of these ways. (A
   and B are the best ways. B is recommended              7. Hold your breath for 10 seconds to allow the
   for young children, older adults, and those               medicine to reach deeply into your lungs.
   taking inhaled steroids. C is okay if you are          8. Repeat puffs as prescribed. Waiting 1 minute
   having trouble with A or B.)                              between puffs may permit the second puff to
   A. Open mouth with inhaler 1 to 2 inches                  go deeper into the lungs.
      away.                                               Note: Dry powder capsules are used differently.
   B. Use spacer (ask for the handout on spacers).              To use a dry powder inhaler, close your
                                                                mouth tightly around the mouthpiece and
                                                                inhale very fast.


   A                                B                                             C




                                                                                                     59
CLEANING                                                                   CHECKING HOW LONG A CANISTER
1. Once a day clean the inhaler and cap by rins-                           WILL LAST
   ing it in warm running water. Let it dry before                         1. Check the canister label to see how many
   you use it again. Have another inhaler to use                              “puffs” it contains.
   while it is drying. Do not put the canister
   holding cromolyn or nedocromil in water.                                2. Figure out how many puffs you will take per
                                                                              day (e.g., 2 puffs, 4 times a day=8 puffs a
2. Twice a week wash the L-shaped plastic                                     day). Divide this number into the number of
   mouthpiece with mild dishwashing soap and                                  puffs contained in the canister. That tells you
   warm water. Rinse and dry well before putting                              how long the canister should last.
   the canister back inside the mouthpiece.
                                                                           Example:
                                                                           Canister contains 200 puffs.
                                                                           You take 2 puffs, 4 times a day, which equal
                                                                              8 puffs/day.
                                                                           200 ÷ 8 = 25. The canister will last 25 days.




Nurses: Partners in Asthma Care, National Asthma Education and Prevention Program,
National Heart, Lung, and Blood Institute, NIH Publication No. 95-3308, 1995.

            60
                   SPACERS: MAKING INHALED MEDICINES EASIER TO TAKE

Unless you use your inhaler the right way, much of the medicine may end up on your tongue, on the back
of your throat, or in the air. Use of a spacer or holding chamber can help prevent this problem.
A spacer or holding chamber is a device that attaches to a metered-dose inhaler. It holds the medicine in
its chamber long enough for you to inhale it in one or two slow deep breaths.
The spacer makes it easy to use the medicines the right way (especially if your child is young or you have a
hard time using just an inhaler). It helps you not cough when using an inhaler. A spacer will also help
prevent you from getting a yeast infection in your mouth (thrush) when taking inhaled steroid medicines.
There are many models of spacers or holding chambers that you can purchase through your pharmacist or
a medical supply company. Ask your doctor about the different models.


HOW TO USE A SPACER
1. Attach the inhaler to the spacer or holding
   chamber as explained by your doctor or by
   using the directions that come with the product.
2. Shake well.
3. Press the button on the inhaler. This will put
   one puff of the medicine in the holding cham-
   ber.
4. Place the mouthpiece of the spacer in your
   mouth and inhale slowly. (A face mask may
   be helpful for a young child.)
5. Hold your breath for a few seconds and then
   exhale. Repeat steps 4 and 5.
6. If your doctor has prescribed two puffs, wait
   between puffs for the amount of time he or she                           There are a variety of spacers.

   has directed and repeat steps 2 through 5.




Nurses: Partners in Asthma Care, National Asthma Education and Prevention Program,
National Heart, Lung, and Blood Institute, NIH Publication No. 95-3308, 1995.


                                                                                                              61
                      HOW TO USE AND CARE FOR YOUR NEBULIZER

A nebulizer is a device driven by a compressed air machine. It allows you to take asthma medicine in the
form of a mist (wet aerosol). It consists of a cup, a mouthpiece attached to a T-shaped part or a mask, and
thin, plastic tubing to connect to the compressed air machine. It is used mostly by three types of patients:
  s   Children under age 5.
  s   Patients who have problems using metered-dose inhalers.
  s   Patients with severe asthma.
A nebulizer helps to make sure you get the right amount of medicine.
Routinely cleaning the nebulizer is important because an unclean nebulizer may cause an infection.
A good cleaning routine keeps the nebulizer from clogging up and helps it last longer. (See instructions
with nebulizer.)
Directions for using the compressed air machine may vary (check the machine’s directions), but generally
the tubing has to be put into the outlet of the machine before it is turned on.


HOW TO USE A NEBULIZER                                   6. Hold each breath 1 to 2 seconds before breath-
1a. If your medicine is premixed, measure the               ing out.
    correct amount of medicine using a clean             7. Continue until the medicine is gone from the
    dropper and put it into the cup. Go to step 2.          cup (approximately 10 minutes).
1b.If your medicine is not premixed, measure             8. Store the medicine as directed after each use.
   the correct amount of saline—using a clean
   dropper—and put it into the cup. Then                 CLEANING THE NEBULIZER
   measure the correct amount of medicine using
                                                         Don’t forget: Cleaning and getting rid of germs
   a different clean dropper and put it into the cup
                                                         prevent infection. Cleaning keeps the nebulizer
   with the saline. (Do NOT mix the droppers;
                                                         from clogging up and helps it last longer.
   use one for saline and another for the medi-
   cine.) Put an “S” for saline on one dropper           Cleaning Needed After Each Use
   with nail polish.                                     1. Remove the mask or the mouthpiece and
2. Fasten the mouthpiece to the T-shaped part               T-shaped part from the cup. Remove the
   and then fasten this unit to the cup OR fasten           tubing and set it aside. The tubing should not
   the mask to the cup. For a child over the age            be washed or rinsed. The outside should be
   of 2, use a mouthpiece unit because it will              wiped down. Rinse the mask or mouthpiece
   deliver more medicine than a mask.                       and T-shaped part—as well as the eyedropper
                                                            or syringe—in warm running water for 30
3. Put the mouthpiece in your mouth. Seal your              seconds. Use distilled or sterile water for
   lips tightly around it OR place the mask on              rinsing, if possible.
   your face.
                                                         2. Shake off excess water. Air dry on a clean
4. Turn on the air compressor machine.                      cloth or paper towel.
5. Take slow, deep breaths in through the mouth.
                                                                                                63
3. Put the mask or the mouthpiece and T-shaped                             Cleaning Needed Once or Twice a Week
   part, cup, and tubing back together and                                 1. Remove the mask or the mouthpiece and
   connect the device to the compressed air                                   T-shaped part from the cup. Remove the
   machine. Run the machine for 10 to 20                                      tubing and set it aside. The tubing should
   seconds to dry the inside of the nebulizer.                                not be washed or rinsed. Wash the mask or
4. Disconnect the tubing from the compressed                                  the mouthpiece and T-shaped part—as well
   air machine. Store the nebulizer in a ziplock                              as the eyedropper or syringe—with a mild
   plastic bag.                                                               dishwashing soap and warm water.
5. Place a cover over the compressed air machine.                          2. Rinse under a strong stream of water for 30
                                                                              seconds.
Cleaning Needed Once Every Day                                             3. Soak for 30 minutes in a solution that is one
1. Remove the mask or the mouthpiece and T-                                   part distilled white vinegar and two parts
   shaped part from the cup. Remove the tubing                                distilled water. Throw out the vinegar water
   and set it aside. The tubing should not be                                 solution after use; do not reuse it.
   washed or rinsed.                                                       4. Rinse the nebulizer parts and the eyedropper
2. Wash the mask or the mouthpiece and T-                                     or syringe under warm running water for
   shaped part—as well as the eyedropper or                                   1 minute. Use distilled or sterile water, if
   syringe—with a mild dishwashing soap and                                   possible.
   warm water.                                                             5. Shake off excess water. Air dry on a clean cloth
3. Rinse under a strong stream of water for 30                                or paper towel.
   seconds. Use distilled (or sterile) water if                            6. Put the mask or the mouthpiece and T-shaped
   possible.                                                                  part, cup, and tubing back together and con-
4. Shake off excess water. Air dry on a clean                                 nect the device to the compressed air machine.
   cloth or paper towel.                                                      Run the machine for 10 to 20 seconds to dry
                                                                              the inside of the nebulizer thoroughly.
5. Put the mask or the mouthpiece and T-shaped
   part, cup, and tubing back together and                                 7. Disconnect the tubing from the compressed
   connect the device to the compressed air                                   air machine. Store the nebulizer in a ziplock
   machine. Run the machine for 10 to 20                                      plastic bag.
   seconds to dry the inside of the nebulizer.                             8. Clean the surface of the compressed air machine
6. Disconnect the tubing from the compressed                                  with a well-wrung, soapy cloth or sponge.
   air machine. Store the nebulizer in a ziplock                              You could also use an alcohol or disinfectant
   plastic bag.                                                               wipe. NEVER PUT THE COMPRESSED
                                                                              AIR MACHINE IN WATER.
7. Place a cover over the compressed air machine.
                                                                           9. Place a cover over the compressed air machine.




Nurses: Partners in Asthma Care, National Asthma Education and Prevention Program,
National Heart, Lung, and Blood Institute, NIH Publication No. 95-3308, 1995.

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